Every finding on record at Haines City Rehabilitation and Nursing Center

Based on observation, interview and record review the facility failed to start a medication timely for one resident (#1) of three residents sampled.Findings included: On 01/13/26 at 9:35 a.m. Resident #1 was observed sleeping with the head of the bed elevated. No odors were noted. A dressing was in place on her left cheek dated 01/12/2026. Her call light was within reach. Resident #1 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to CVA (Cerebrovascular Accident) with hemiplegia, diabetes, stage III chronic kidney disease, hypertension and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a blank Brief Interview for Mental Status (BIMS) score. Section C-Memory- showed resident is rarely/never understood. Section GG showed the resident required substantial / maximal assistance for toileting and bathing/ and partial / moderate assistance for transferring. Review of a progress note dated 12/12/25 at 11:54 a.m. showed the orthopedic office called to give report on resident's status and new treatment orders post-surgery.New order for Tramadol 50mg every 8 hours as needed, Keflex [Cephalexin] 500 mg 4x daily x 10 days. [Family Member] escorted resident to appointment and has been notified of post-surgery orders. Awaiting resident's return. Signed by Staff A, Licensed Practical Nurse, Unit Manager (LPN/UM)Review of the physician orders showed Cephalexin 500 mg (milligrams) to be given 4 times a day (QID) starting 12/13/2025. Review of the December Medication Administration Record (MAR) showed Cephalexin 500 mg give 4 times a day was started on 12/13/2025 with the 5 p.m. and 9 p.m. doses administered. The review showed the Cephalexin 500 mg was not entered in Resident #1's physician orders on 12/12/2025, resulting in Resident #1 missing two doses. The review further showed on 12/14/25 the 9:00 a.m. dose was held, resulting in a delay of 4 doses and one more dose not administered on 2/14/25 at 9 a.m., a total of five missed doses. Review of the progress notes showed on 12/13/25, at 2:29 p.m. Cephalexin 500 mg entered give QID post- surgical for 10 daysReview of the progress notes showed on 12/14/25, at 8:16 a.m. Cephalexin, awaiting on MD approval to administer due to allergies to penicillin. Resident #1 did not receive the 9 a.m. dose. Review of the care plans showed the resident at risk and / or have actual impaired cognitive function/impaired thought processes related to CVA as of 04/23/2025. Interventions included but not limited to administer medications as ordered. During an interview on 01/13/2026 at 1:48 p.m. Staff A, LPN/UM, nurse for Resident #1 stated the resident usually goes with the family for her procedures. She stated the transportation person would give the paperwork to our staff if it was given to her. Staff A stated they had been unable to find any paperwork from the resident's ortho doctor. Staff A stated, You are correct, we should be getting the orders from the doctor not depending on the family to give them to us. Staff A stated she wrote the note about the antibiotic order on 12/12/2025. Staff A stated she gave the orders to the floor nurse on 12/12/2025. Staff A stated, My bad, it may not have been put in until the next day by the resident's nurse. I should have put the orders in myself. Staff A verified the resident had a delay of 4 doses. Staff A stated they may have been able to get the medication out of the emergency medications kit. Review of the facility's policy titled, Physician Orders, revised 01/2024, showed orders and administration of medications and treatments will be consistent with principles of safe and effective order writing. Procedure:1. Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable.2. Authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.3. Drug and biological orders must be recorded on the physician's order sheet in the residence electronic chart.5. Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name credentials, the date and the time of the order.6. Orders should be transcribed by the authorized person receiving the order and recorded in the resident's medical record.7. The entry should contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.9. Physician order should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated. Review of the facility's policy titled, Medication Administration, revised 01/2024 showed medications are ordered and administered safely and as prescribed.3. Medications are administered in accordance with prescribing orders, including any required time limit.5. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and or need for additional staff training.7. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observation, record review, and interview, the facility failed to ensure the care plans for eight (#34, #52, #30, #91, #36, #39, #67, and #90) of 48 residents were developed and implemented related to activities, Hospice, and fall devices. Findings included: 1. On 11/18/24 at 10:46 a.m., Resident #34 was observed sitting in a wheelchair between the bed and bathroom wall. The resident was smiling and nodding at this writer, neither of the televisions for the resident or roommate was on or was there radio playing. On 11/19/24 at 9:59 a.m., Resident #34 was observed lying flat in bed, the room did not have a television or radio playing. On 11/20/24 at 9:00 a.m., Resident #34 was observed sitting in wheelchair between the bed and bathroom wall. The observation revealed a Spanish-speaking Activity calendar posted on the wall slightly behind the television which was not turned on. Review of Resident #34's Admission Record showed the resident had diagnoses not limited to primary open-angle glaucoma unspecified eye stage unspecified and unqualified visual loss both eyes. Review of Resident #34's care plan revealed the following care areas and related interventions: - Resident has impaired visual function related to (r/t) blindness, initiated 6/11/23. - Resident has a communication problem related to (r/t) language barrier: Spanish-speaking, understands some English, (and) has some hearing impairment. The interventions instructed staff, including Activity staff, to Provide translator if resident needs and or wants one to communicate with the resident, initiated 9/26/24. - Resident is dependent on staff for emotional, intellectual, physical, and social stimulation r/t cognitive deficits (and) physical limitations. The goal showed The resident will increase/tolerate involvement in cognitive stimulation, social activities as desired through review date. The interventions instructed staff to: o Assist with arranging community activities. Arrange transportation. o Assist/escort to activity functions as needed. o Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, (and) meals. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #34 had minimal difficulty with hearing, was usually understood, usually made self understood, and vision was severely impaired, no vision or sees only light, colors or shapes. The comprehensive assessment revealed a daily and activity preferences were discussed with the resident's family member or significant other. The preferences showed that listening to music, doing things with groups of people, doing a favorite activity, going outside for fresh air, and participating in religious services or practices were very important to the resident. Review of Resident #34's Activity documentation showed the resident actively participated in the activity of Friend/Friendly Visit in the resident's room/on unit 20 of 30 opportunities from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any offered activity. Review of Resident #34's Lifestyle and Activity Preferences Evaluation, effective 8/26/24, revealed the resident's religious preference, was Hispanic, vision was impaired and not improved by glasses or contacts, no problem with hearing, had difficulty in finding words, poor reading ability, needed reminder at time of activity, was not bed/room bound, and needed no assistance to/from activity setting. The evaluation showed the resident enjoyed friendly visits by staff, enjoyed crafts in the past, enjoyed church services, enjoyed hand massages, and enjoyed visiting with select staff members. 2. On 11/20/24 at 8:44 a.m., Resident #52 was observed lying in bed, in a room without a roommate. The room did not have a television or radio available for the resident. On 11/21/24 at 8:37 a.m., Resident #52 was lying in bed and wearing a hospital gown. The blinds to the room were closed leaving the room dark with no available television or radio. Review of Resident #52's care plan revealed the following care areas and related interventions: - Has potential for little or no activity involvement related to (r/t): language barrier; Impaired thought process; Dementia. At times chooses to observe activities rather than participate, often chooses to remain in bed. The resident's goal was to increase participation in activities of choice times per week by review date of 2/1/2025. The goal was revised 11/11/24. The interventions instructed activity staff to: o Encourage resident to participate in activities that's tolerated. o Invite/ encourage the residents family members to attend activities with resident as needed/ desired. o Offer friendly visits to promote independent leisure pastimes in socialization. o Remind the resident that the resident may leave activities at any time and is not required to stay for the entire activity. o Resident requires (specific interventions i.e. cueing) to engage in activities of interest, o The resident needs a variety of activity types and locations to maintain interests. The Certified Nursing Assistants (CNA) were instructed the resident needs assistance/ escort to activity functions. - Has a communication problem related to impaired cognition, primary language is Spanish, revised 11/11/24. The goal was for the resident would maintain current level of communication function through the review date of 2/1/25. The interventions included: o provide a program of activities that accommodates the residents communication abilities, initiated 11/11/24. o Provide translator as necessary to communicate with the resident. Review of Resident #52's annual comprehensive assessment, dated 10/15/24 showed the resident did not have a Brief Interview of Mental Status score as the resident was rarely/never understood. The staff assessment of the resident's cognition showed a short-and long-term memory problem, severe impairment for making decisions regarding tasks of daily life, with no acute change in mental status, the behaviors of inattention, disorganized thinking, and altered level of consciousness were not present. The activity preferences were completed with the resident revealing music and religious services were somewhat important. The quarterly Activity Progress note dated 7/27/24 showed the activity assessment was complete and appropriate. The preferred activities were watching television, people watching, listening to music, and visiting with select staff members. Resident expresses satisfaction with current routine and staff will continue to provide 1:1 visits and encouragement for participation in group programs. Review of Resident #52's Activity documentation showed the resident actively participated in the activity of Friend/Friendly Visit 19 of 30 opportunities and one episode of receiving mail from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any activity. 3. On 11/19/24 at 11:05 a.m., Resident #30 was observed lying in bed. The resident acknowledged going to activities sometimes and reported not being informed of daily activities. On 11/21/24 at 12:31 p.m., Resident #30 stated activity staff did not visit daily for 15-20 minutes per day. Review of Resident #30's care plan showed the resident had little or no activity involvement related to physical limitations, chooses to remain in bed at times. Requires much encouragement for group participation. Resident attends outings. The goal for the resident was the resident would express satisfaction with type of activities and level of activity involvement when asked through the review date. The goal was revised on 7/8/24 with a target date of 12/11/24. The interventions instructed activity staff to: - Encourage participation and activities of potential interest. - Encourage resident to participate in activities as tolerated. - Invite/ encourage the resident's family members to attend activities with resident as needed/ desired. - Offer friendly visits to promote independent leisure pastimes and socialization. - Remind the resident that the resident may leave activities at any time and is not required to stay for the entire activity. The CNA's are instructed the resident needs assistance/ escort to activity functions. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status score of 15 of 15, indicating an intact cognition. The annual MDS dated [DATE] revealed the resident's activity preferences of having pets around was very important and reading materials, listening to music, keeping up with the news, doing things with groups of people, doing favorite activities, going outside, and participating in religious services were somewhat important. Review of Resident #30's Activity Documentation showed the resident actively participated in the activity of Friend/Friendly Visit 18 of 30 opportunities, one insistence of an animal/pet visit, and one episode of beauty/grooming from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any activity. 4. On 11/19/24 at 11:05 a.m Resident #91 was observed lying in bed, the resident reported attending activities sometimes. The activity calendar was posted on the wall opposite of where the resident's bed was located and behind the television. The resident and roommate (#30) stated they were not informed of daily activities and were unable to read the calendar from it was located. On 11/21/24 at 12:31 p.m., Resident #91 reported Activity staff did not visit daily for 15-20 minutes and they did not read or talk with her daily. Review of Resident #91's care plan revealed the following care areas with related interventions: - The resident is able to make leisure needs and preferences known in participate in facility activities as desired. Prefers independent leisure activities with encouragement. Resident attends outings, revised 9/30/24. The goal for the resident shows the resident will remain engaged in independent leisure activities and participate in facility activity programming as desired through next review. The resident will express satisfaction with leisure routine through next review. The target date was 1/29/25. The interventions were related to this care area instructed activity in nursing staff to: o assist resident to/ from activities as needed. o Encourage in room leisure time such as TV, phone/ video communication with family/ friends, reading books/magazines, etcetera and allow for resident feedback and suggestions on leisure time activities. o Encourage ongoing family involvement. Invite the residents family to attend special events, activities, (and) meals. o Encourage participation in activities of interest. o Honor residents choice to choose only activities, provide reminders/ cues for participation as needed. - The resident has a psychosocial well-being problem related to self-reporting that (pronoun) not very interested in favorite activities. This area was initiated on 11/11/24. Review of Resident #91's annual comprehensive assessment showed being around animals was very important to the resident and listening to music, doing things with groups of people, going outside to get fresh air, and participating in religious services was somewhat important to the resident. Review of Resident #91's Activity Documentation showed the resident actively participated in the activity of Friend/Friendly Visit in the resident's room/on unit 20 of 30 opportunities, from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any activity. On 11/19/24 at 10:45 a.m., the Activity Room was observed with stacks of boxes and desks around the perimeter of the room. Staff W, Activity Director of sister facility, reported doubting any activities were happening in the Activity Room as it was more of an office and the residents store things in there. An interview was conducted on 11/21/24 at 9:26 a.m., with Staff O, Licensed Practical Nurse/Unit Manager. The staff member stated Resident #34 did not do things like before, two weeks ago the resident went to music and wanted to be brought back within 5 minutes. Staff O reported the resident spoke English, don't let her fool you. The staff member stated Resident #34 did not want to get up (out of bed) and thought it was in the resident's care plan. Staff O reviewed the resident's care plan reporting the issue with not wanting to get out of bed was not part of the care plan. The staff member stated Activity (staff) came around daily and offered activities. An interview was conducted on 11/21/24 at 10:15 a.m., with the Activity Director (AD). The AD stated daily visits were done daily and lasted about 10-15 minutes. During an interview on 11/21/24 at 10:46 a.m. with the AD and Nursing Home Administrator (NHA), the AD reported doing 1:1 activities with music, audiobooks, and singing with Resident #34. She reported playing music yesterday for the resident for 15 minutes. The AD reported activity staff do not speak Spanish but pulled Spanish -speaking staff into the room to speak with the resident. The AD reported Resident #52 was Spanish-speaking and staff performed hand massages and read to the resident every day as the resident did not participate in group activities. The AD reported not reading the activity calendar to residents and said activities were announced through the facility's overhead system (not heard during survey). The NHA stated they had put in a system so the aides brought residents down to activities and were aware of the activities. Resident #91 did not participate in activities and Resident #30 was very specific on activities. Resident #52 liked to have blinds closed in room and the NHA stated the resident would yell out to people in the hallway. 50732 5. On 11/18/2024 at 11:01 a.m., Resident #39 was observed laying in bed under the covers, dressed in a gown, groomed and sleeping. The resident was receiving nutrition via tube feeding. A verbal attempt was made to wake the resident up by calling her name, however, the resident opened her eyes and immediately closed her eyes. No visitors or staff were observed in the room. On 11/19/2024 at 10:27 a.m., Resident #39 was observed laying in bed under the covers, dressed in her personal clothing, groomed and awake. An attempt at verbal communication with the resident was made by calling out her name, however, the resident continued to stare and did not verbalize a response. No visitors or staff were observed in the room. On 11/21/2024 at 3:30 p.m., Resident #39 was observed laying in bed under the covers, dressed in her personal clothing, groomed and awake. An attempt at verbal communication with the resident was made by calling out her name, however, the resident continued to stare and did not verbalize a response. No visitors or staff were observed in the room. Review of the Admission Record showed Resident #39 was admitted to the facility with diagnoses included but not limited to Alzheimer's Disease, gastrostomy, history of falling, need for assistance with personal care, contracture left elbow, contracture left hip, dysphagia, cognitive communication deficit, and contracture right hip. Review of Resident #39's Minimum Data Set (MDS) Quarterly assessment dated [DATE] showed Section C-Cognitive Patterns, Resident #39 had a Brief Interview for Mental Status (BIMS) score of 00 showing severe cognitive impairment. Section GG-Functional Abilities and Goals showed when Resident #39 was seated in a motorized wheelchair/scooter, she had the ability to wheel at least 50 feet and make two turns. Section GG also showed when Resident #39 was seated in a manual wheelchair, she had the ability to wheel at least 150 feet in a corridor or similar space. Review of Resident #39's Care Plan dated 09/24/2024 revealed the resident was dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits. Resident #39 needed Assist/escort to activity functions as needed. The resident should be invited to scheduled activities. Offer 1:1 bedside/in-room visits/activities if the resident was unable to attend out-of-room events, if the resident chooses. Review of Quarterly Activity Progress note dated 09/25/2024 for Resident #39 showed the following: 1. Assessment Review - activity assessment is complete and appropriate. No changes needed. 2. Activities-related care plan: some elements/interventions were successful: 1:1 visits provided by staff 3. Summary - since the last review the resident has enjoyed these preferred activities: Resident enjoys a variety of activities mainly receiving friendly visits, being read aloud to, hand massages, and listening to music. Resident prefers to stay in bed majority of the time. The positive results included: Resident expresses satisfaction with current routine through facial expressions. Staff will continue to provide 1:1 visits. Review of Resident #39's Activity Participation Report, as completed by the Activities Department staff, showed for the time period 10/23/2024 through 11/20/2024 the section titled Active was checked daily. The other sections were not checked and were titled as follows: Left or In & Out, Passive/Assisted, Present/Observer (difficult to discern response), Therapy Session at time of activity, Visiting with family/other (at time of activity), Resident Not Available, Resident Refused and Not Applicable. Review of Resident #39's Activity Type Report, as completed by the Activities Department staff, showed for the time period 10/23/2024 through 11/20/2024 the section titled Friend/Friendly Visit (e.g. may include by staff, volunteer) was checked daily. All other sections of the report were not checked. The sections not checked included: Memory Stimulation (e.g. reminiscing, photos), Music and Nature/Garden/Science. An interview was conducted on 11/21/2024 at 10:46 a.m. with Staff G, Activities Director (AD) and the Nursing Home Administrator (NHA). Staff G said there were three staff members in the Activities Department, herself and two others. She said friendly visits were done in the morning between 9:30 a.m. and 10:00 a.m. and the visits usually took 15-20 minutes for each resident. She said friendly visits were also completed during any downtime her and her staff might have during the day. Staff G said the resident visits were charted by the activities staff and the charting was usually done at the end of the day. She said the exact times of the visits were sometimes not charted correctly because the facility's electronic medical record automatically records a time and the staff sometimes forgot to change the time when completing their charting. Staff G said the Activities department individually charts what activity they do with the residents. For example, reading, listening to music, etc. were not separately charted because charting as friendly visits encompasses the other activities done on the 1:1 friendly visits. She said the activities staff meet every morning and discuss what types of visits they completed with their assigned residents the day before. Staff G said she did not actually time her staff to ensure they were spending time with their assigned resident, she received the information directly from the staff members. She agreed as a Director of Activities she needed to know exactly how long each staff member was spending with their assigned residents. 46498 6. During an observation made on 11/19/24 at 11:46 a.m., and 2:00 p.m., Resident#67 was observed lying down in his bed during an activity. He stated he did not participate in activities because staff did not offer him activities. Review of Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment Resident #67 had a care plan showing he had potential for little or no activity involvement related to a language barrier, weakness. Date 9/19/2022, Revision on 9/22/2022. The care plan goals were for Resident #67 would increase participation in activities of choice (sic) times per week by review date. Date initiated 9/19/2022, Revision on 7/18/2024, Target date 12/28/2024. The care plan intervention included: Encourage participation in activities of potential interest including (sic). Resident #67 needed assistance/escort to activity functions, the resident needed a variety of activity types and locations to maintain interests. Date initiated 9/19/2022. During an interview on 11/21/2024 at 2:00 p.m., with Staff G, Activity Director. Staff G stated every month they made up packets to hand out to every resident that showed the upcoming activities. She stated on the packet she highlighted what activities she knew each resident would like to attend, so residents could see the activity that would interest them. She stated her and her staff go around to residents' rooms to invite residents to activities every day, but she did not document if a resident refused to participate in activities. She stated Resident #67 always refused activities when they asked him if he would like to participate but she did not document her attempts. She stated she just recently started working in the position and she had not reviewed each resident's care plan to know what their intervention were and to ensure that the resident interventions were followed. 50434 7. During an observation on 11/18/2024 at 9:49 a.m. Resident #90 was observed in bed dressed in a night gown, clean in appearance. An attempt to interview Resident #90 was made and she was not able to answer questions regarding her care. Review of Resident 90's admission Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) of 04 out of 15 which indicated severe cognitive impairment. Review of Section O. Special Treatments revealed Hospice care. A review of Resident #90's care plan revealed no focus, goal or interventions related to Resident #90 receiving Hospice Services. During an interview on 11/20/2024 at 11:40 a.m., Staff T, Certified Nursing Assistant (CNA), stated Resident #90 needed assistance with all of her care. She stated Resident #90 liked to try to do everything on her own and goes fast. She stated she thought the resident was being seen by the hospice. She stated she thought the Hospice CNA came in and saw her on Tuesdays. During an interview on 11/20/2024 at 11:40 a.m., Staff U, Licensed Practical Nurse (LPN), stated the paper chart was where they kept the orders for residents on hospice. He stated it could also be found in the resident's profile in [name of computer program]. He stated the Hospice CNAs made their own schedules and did not have set days to come in. He stated the Hospice Nurse came in once a week and would come to the nurse's station to let him know they were seeing the residents. He stated if the nurse had new orders or was changing anything they write it out on an order sheet and gave it to the nurse, who then put the orders into [name of computer program]. During an interview on 11/20/2024 at 1:50 p.m., Staff O, LPN, stated when Hospice notified the facility they were accepting the resident, the nurses add the Hospice order into [name of computer program]. She stated Hospice would do an initial care plan for the residents. She stated the hospice nurse came one or two times a week. Hospice CNAs came in two times a week unless it was requested for more by the family. If staff at the facility had any concerns or if there was a change in condition with the resident, the nurse would notify hospice. She stated Resident #90 was on hospice prior to coming into the facility. She reviewed the orders and was not able to locate the hospice order for Resident #90. She reviewed Resident #90's care plan and stated, the care plan has hospice under nutrition, but it is not clear. She located Hospice's care plan in the document section of Resident #90's chart and stated the facility would not add their own hospice care plan for the resident and would just use the one hospice had. She stated the MDS Director was responsible for doing the care plans for the residents. During an interview on 11/20/2024 at 2:14 p.m., MDS Director, stated Resident #90 was receiving hospice services. She stated the hospice nurses attend the care plan meetings either by phone or in person. She reviewed Resident #90's care plan and stated she saw the hospice under nutrition, but they typically had a care plan for hospice/palliative care that she would add as well. 20536 8. On 11/18/2024 at 9:55 a.m. and 2:00 p.m., 11/19/2024 at 7:30 a.m., 3:15 p.m., 11/20/2024 at 8:07 a.m., 10:00 a.m., 11:30 a.m. 12:21 p.m., 1:45 p.m., 2:00 p.m., 3:00 p.m., and on 11/21/2024 at 7:20 a.m., Resident #36 was observed each time in his room, lying flat in a low bed and completely under the bed linen and covers. He was also noted each time with the linen pulled up over his entire head. It was further observed two very large, long and high raised fall floor mats devices on the floor on each side of the bed. The tops of both the fall mats were observed level to the top of the low bed mattress and appeared to be used should the resident roll out from bed. It was also observed Resident #36 had both 1/4 side rails up and in position while he was in bed. Photographic evidence obtained. On 11/18/2024 at 9:55 a.m., an interview was attempted with Resident #36. He did not respond to any questions. During the dates and times mentioned above, and while Resident #36 was in his bed, on 11/19/2024 at 7:30 a.m. and 3:15 p.m. the right side fall floor mat was observed folded and positioned behind the divider curtain, which was on Resident #36's roommate's side of the room. It was observed there was bare floor space approximately three feet from the edge of Resident #36's side of the bed and to where the fall floor mat was placed. On 11/20/2024 at 8:07 a.m., the right side raised fall mat for Resident #36 was again observed folded and slid over past the divider curtain, leaving about three feet of bare floor space from the edge of the bed and to the fall mat. On 11/20/2024 at 8:09 a.m., Staff E, a Certified Nursing Assistant (CNA) walked into the room. She revealed the raised fall mats were used for the resident because he sometimes rolled out of bed and onto the floor. She said the side rails were used as enablers and were not restraints. Staff E further revealed she was not sure why the mats were so large other than so he did not roll on to the floor. The bed was in the lowest position but the mats were approximately one to one and a half feet high up off the ground. Staff E said Resident #36 did not get up out of bed on his own and he did not ambulate. Review of the current Physician's Order Sheet dated for the month 11/2024 and 10/2024 did not show any specific order for the use of fall floor mats or any type of special fall/accident devices. Review of the nurse progress notes dated from 6/1/2024 through to 11/21/2024 did not reveal any documented evidence of use of any type of fall floor mats, or any type of special fall/accident devices. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the following; Cognition/Brief Interview Mental Status BIMS score - 00 of 15, which indicated severe cognitive impairment; Mood - None documented as observed during this assessment timeframe; Behaviors - None documented as observed during assessment timeframe. Review of the current Care Plans with a next review date of 12/16/2024, showed the following: 1. Resident has a history of preferring stay in bed on most days. Snacks in bed. Prefers not to be weighed. Refuses showers with interventions to include but not limited to: Acknowledge/commend the resident's progress/improvement in behavior; Administer medications as ordered. Monitor/document for side effects and effectiveness; If reasonable/appropriate, discuss the behaviors with the resident. Explain/reinforce why behavior is inappropriate and/or unacceptable; Monitor behavior episodes and attempt to determine undying cause. Consider location, time of day, person involved, and situations. Document behavior and potential causes. There were no interventions to support the use of any fall floor mats or specialized fall/accident devices. Review of the entire care plan did not reveal any problem areas or interventions related to Resident #36 using fall floor mats or specialized fall/accident devices, while in bed. Further review of the entire medical record, there was no evidence of Resident #36 using these devices while in bed. On 11/21/2024 at 9:30 a.m., an interview with Staff F, Care Plan Coordinator, revealed she did know Resident #36 and his general daily care and routines. She said he was declining and received Hospice services and has had falls in the past. Staff F was asked about the large raised fall mat devices on each side Resident #36's bed. She revealed they were used as safety devices to help when he either placed his legs and feet off the side edge of the bed, or when he rolled out of bed. She said the mats were raised to a point that if he rolls off, he would roll onto these devices. Staff F further confirmed Resident #36's bed was always set at the lowest position and he also utilized 1/4 bed rails for enabling/repositioning. Staff F reviewed the electronic medical record to include the current 11/2024 Physician's Orders, all the nurse progress notes for the last three months (11/2024, 10/2024, 9/2024), and the current care plans and could not find evidence of these fall mats documented as ordered and reason for use. She further confirmed these devices were not listed in any of the problem areas in the current care plans. She revealed he had been care planned for use of these devices in the past, but it was confirmed these devices were not brought over during the last care plan meeting, which was in 9/2024. On 11/21/2024 at 10:03 a.m. an interview with the Director of Nursing (DON) confirmed Resident #36 required safety devices related to his risk for falls and history of falls. The DON revealed the large raised fall mat devices were not initially used as a first intervention for falls, but the Interdisciplinary Team had later added these devices. She confirmed the devices were not ordered an [TRUNCATED]

Based on observations, interviews, and record review, the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 11/18/2024 through 11/21/2024 as evidenced by: 1.) failure to provide a safe, clean, and homelike environment for one (B Hall) of two community shower rooms (F584), 2.) failure to ensure blood glucose levels were checked and insulin was administered timely for two residents (#1 and #2) out of three residents reviewed for insulin administration and failed to administer anti-viral medication for one resident (#3) out of one resident reviewed for flu treatment (F684) and 3.) failure to implement an effective Infection Control program as evidenced by staff members not using personal protective equipment (PPE) for two residents (Resident #3 and Resident in room [ROOM NUMBER]) out of 11 on transmission based precautions (TBP) and two out of six residents observed during medication administration (F880). Findings included: Review of the facility's Quality Assurance/Performance Improvement Plan (QAPI), with a revision date February 23, 2021, revealed: Vision To pioneer healthcare by creating a compassionate, memorable and dignified experience for every person we serve. We strive to treat our patients, their families and our staff with the highest level of dignity and respect by promoting an environment of continuous improvement and service excellence. Mission We at [another healthcare facility name] are committed to the physical, emotional and spiritual well-being of our residents. We strive to provide excellent service for residents of every culture in a supportive, caring, homelike environment and to maintain a high level of dignity and individuality. Values Passion: We are strongly compelled to provide great care to every resident we serve. Respect: We feel deep admiration for others and their abilities, qualities and achievements. Integrity: We do the right thing for the right reasons. Dedication: We are committed to providing great care. The staff will utilize data from industry standards to quantify and benchmark all aspects of performance improvement whenever possible. Any negative trends in data will be addressed utilizing root cause analysis and quality improvement methodologies. The leadership and staff will embrace the evidence-based strategies and utilize PDSA cycles until the desired change is effective and the desired goals are achieved and sustained. Governance and Leadership The governing body and/or administration of the nursing home will develop a culture that involves leadership seeking input from facility staff, residents and their families/representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. [Another healthcare facility name] governing body is ultimately responsible for overseeing the QAPI Committee. The owner/CEO has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. A facility-wide training will be conducted to inform everyone in the facility about the QAPI Program. These trainings will be conducted often and in multiple ways through (e.g. in services, department head in services, examples, exercises, etc.) Every caregiver will be made to understand that they are expected to raise quality concerns, that it is safe to do so, and that everyone is encouraged to think about systems. The QAPI approach at [another healthcare facility name] will also be communicated to consultants, contractors and collaborating agencies, to make them understand that they each have a role in the QAPI plan. [another healthcare facility name] will ensure that all residents and families are aware of the facility's QAPI program, and that their views are sought, valued and considered in facility decision-making and process improvements. The QAPI program will be announced and discussed at the resident council meetings, and other resident and family events/venues. Feedback, Data Systems and Monitoring [Another healthcare facility name] will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigation and monitoring events every time they occur, and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences. The QAPI team at [another healthcare facility name] will decide what data to monitor routinely. Areas to consider may include, but not be limited to, the following examples: - Clinical care areas (e.g. pressure ulcers, falls, infections) - Medications (e.g., those that require close monitoring, antipsychotics, narcotics) - Complaints/grievances from residents and families - hospitalization s and other service use - Resident satisfaction - Caregiver satisfaction - Care plans, including ensuring implementation and evaluation of measurable interventions - State survey results and deficiencies - Results from MDS resident assessments - Business and administrative processes (e.g., financial information, caregiver turnover, caregiver competencies and staffing patterns, such as permanent caregiver assignment). Data related to caregivers who call out sick or unable to report to work on short notice, caregiver injuries and compensation claims may also be useful. Targets for performance in the areas that are being monitored will be set by the QAPI team. The target will usually be stated as a percentage. Benchmarks for performance such as Nursing Home Compare (www.medicare.gov/nhcompare), CASPER report, Facility Inhouse Benchmarking, etc. will be used to monitor facility progress. Performance Improvement Projects (PIP) The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment. In addition, the QAPI Steering Committee will implement any PIP topics indicated by date analysis. Quality improvement activities are also developed in collaboration with the support of providers, residents, families and staff. PIPS are implemented in accordance with CMS' protocol for conducting PIPS, including: 1. Measurement of performance using objective quality objective indicators 2. Implementation of system interventions to achieve improvement in quality 3. Evaluation of the effectiveness of the interventions 4. Plan and initiation of activities for increasing or sustaining improvement During an interview on 1/16/2025 at 5:55 p.m., the Nursing Home Administrator (NHA) stated the Quality Assurance (QA) Committee includes himself, the Medical Director, the Director of Nursing (DON), and other department heads. The NHA said he was the Committee Chairperson and the QA Committee meets on the third Thursday of every month, although they have not met this month. The NHA stated a QAPI meeting was conducted on 12/18/2024 to discuss the survey results and plan of correction that was submitted to the State Agency. The NHA stated the facility did not conduct another QAPI meeting in January, even though the third Thursday had past, but then stated, the month is not over yet, we will have one. The NHA stated during the meeting in December, they spent the entire meeting on going over the 2567 and developed action plans based on the situations referenced in the survey. 1.) On 1/16/2025 at 9:58 a.m., the shower room on B hall was observed with a housekeeping employee packing up their supplies, placing a wet floor sign at the door, and about to exit the room. A shower bed was observed in the room. Upon lifting the foam mat sitting on top of the mesh of the shower bed, the back of the foam mat had unidentifiable black spots and various clumps of hair covering almost the entire middle section. The mesh part of the bed was observed with dried brown, black, and white stains on the majority of the mesh. Next to the shower bed was a shower chair. The chair was observed with brown/black substance with hair clumps intermingled on all four shower legs above the wheels. At the joints of the four legs was a pink colored substance above and below the joints. The mesh backing of the shower chair had a buildup of a black substance on all three straps. During an interview on 1/16/2025 at 5:55 p.m., the NHA and DON stated nursing and housekeeping are responsible for cleaning the shower rooms. The NHA and DON reviewed the photos of the shower room on B hall and acknowledged the equipment was dirty. 2.) An observation was conducted during medication administration on 1/16/25 at 12:05 p.m. with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN was preparing to administer medication to Resident #1 and had to go to the dining room to get the resident to check his blood glucose level and administer insulin. Resident #1 said he had already finished eating lunch. He said the nurses often check his blood glucose after meals and not before, they are usually late. Staff A, LPN checked Resident #1's blood glucose and it was observed to be 309. The nurse told the resident she was going to administer 15 units of Humalog insulin. Staff A, LPN was observed priming the Humalog insulin pen and setting it to 15 units. The resident refused the 15 units of insulin, saying his blood glucose level would drop too low if he had that much. The nurse called the doctor and received a one-time order for 10 units of Humalog insulin, which was administered at 12:24 p.m. Review of the Admission Record showed Resident #1 was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus (DM) with hypoglycemia. Review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Review of Resident #1's January 2025 physician orders showed the following orders: - Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (units per milliliter) (Insulin Lispro). Inject 15 unit subcutaneously in the morning for DM. Scheduled for 9:00 a.m. Dated 12/8/24. - Insulin Lispro (1 unit dial) 100 unit/ml solution pen-injector. Inject as per sliding scale. Scheduled at 7:05 a.m., 11:30 a.m., and 4:30 p.m. Dated 4/12/24. Review of the Medication Admin Audit Report from 1/2/25 to 1/16/25 showed Resident #1's Humalog was administered late on 7 of 14 opportunities. Resident #1's Insulin Lispro was administered late on 23 of 42 opportunities. An interview was conducted on 1/16/25 at 5:50 p.m. with Staff C, LPN. She said at the time of the interview, all meals had been delivered to residents. Therefore, all blood glucose checks should have been done, because those should be checked prior to eating. An observation and interview was conducted during medication administration on 1/16/25 at 5:57 p.m. with Staff B, LPN. Staff B, LPN was preparing to administer medication to Resident #2. Staff B, LPN was observed entering Resident #2's room to check her blood glucose level. The resident was already eating her dinner at the time. Staff B, LPN confirmed blood glucose levels should be checked prior to meals. Review of the Admission Record showed Resident #2 was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus with neuropathy. Review of Resident #2's January 2025 physician orders showed the following orders: - Insulin Lispro (1 unit dial) Subcutaneous solution pen-injector 100 unit/ml. Inject per sliding scale for times a day for DM. Dated 10/28/24. Scheduled times were 6:00 a.m., 12:00 p.m., 2:00 p.m., and 10:00 p.m. The order times changed on 1/10/25 to 6:00 a.m., 12:00 p.m., 5:00 p.m., and 10:00 p.m. - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ml. Inject 12 units subcutaneously one time a day for DM. Dated 10/28/24. Scheduled at 9:00 a.m. Review of the Medication Admin Audit Report from 1/2/25 to 1/16/25 showed Resident #2's Insulin Lispro was administered late 2 times, early 3 times, and not administered 6 times out of 56 opportunities. Insulin Glargine was administered late 5 out of 14 opportunities. An interview was conducted on 1/16/25 at 6:20 p.m. with the DON. The DON reviewed Resident #1's record and confirmed the resident's blood glucose level should have been checked between 8:00-10:00 a.m. and the Humalog should have been administered then. She said the Humalog was scheduled at 9:00 a.m. for Resident #1. She also said typically when a nurse is running behind, herself or the unit managers jump in to help. The DON said blood glucose levels should be checked before a resident eats their meals and the insulin should be given at mealtime. An observation was conducted on 1/16/25 at 9:25 a.m. of Resident #3's room with a droplet precautions sign hanging on the door. Review of the Admission Record showed Resident #3 was admitted on [DATE] with diagnoses including chronic pulmonary edema and dementia. Review of Resident #3's care plan showed a Focus of The resident has infection: flu exposure, initiated 1/11/25. Interventions included droplet precautions, administer anti-viral per MD (medical doctor) orders, and administer treatment per physician orders. Review of Resident #3's January 2025 physician orders showed an order for: - Tamiflu Oral Capsule 75 mg (milligrams). Give 1 capsule by mouth two times a day for exposure to flu for 5 days. Start date 1/13/25. Discontinue date 1/18/25. Review of Resident #3's Medication Administration Record (MAR) for January 2025 showed Tamiflu was not available for the 9:00 a.m. dose on 1/13/25. Tamiflu was signed off as given on 1/13/25 at 9:00 p.m., 1/14/25 at 9:00 a.m. and 9:00 p.m., and 1/15/25 at 9:00 a.m. and 9:00 p.m., and marked not available at 9:00 a.m. on 1/16/25. An interview was conducted on 1/16/25 at 4:55 p.m. with Staff D, Registered Nurse (RN). Staff D, RN said he was assigned to Resident #3. He checked the medication cart and said there was no Tamiflu in the medication cart for Resident #3. An interview was conducted on 1/16/25 at 5:10 p.m. with a representative from the facility's pharmacy. The pharmacy said no Tamiflu was dispensed for Resident #3. An interview was conducted on 1/16/25 at 5:04 p.m. with the DON and Assistant Director of Nursing/Infection Preventionist (ADON/IP). They both reviewed Resident #3's medical record. The DON said she would not expect the Tamiflu to be signed off since it was not given. She said it should have been documented the medication was not administered and the doctor should have been called. The ADON/IP said she did not see any notes in Resident #3's medical record indicating the doctor was notified the Tamiflu was not given or was not available. The DON confirmed there were no notes in the record. Review of a facility policy titled Standards and Guidelines: Medication Administration, with a revision date of 01/2024 revealed the following: Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber's orders, including any required time frame. 6. Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime). 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering shall document the rationale in the resident's medical record and notify the physician and responsible party if indicated. 3.) An observation was conducted on 1/16/25 at 9:34 a.m. during medication administration with Staff G, LPN. Staff G, LPN was observed completing medication administration for a resident without performing hand hygiene. She began preparing medication for a second resident, entered the second resident's room, and took vital signs. Staff G, LPN exited the room, placing the blood pressure cuff on the medication cart prior to cleaning it. Staff G, LPN put on gloves and cleaned the blood pressure cuff, removed the gloves, and did not perform hand hygiene before continued to prepare and administer medication for the resident. An observation was conducted on 1/16/25 at 11:55 p.m. during medication administration with Staff A, LPN. Staff A, LPN was observed wearing gloves to prepare medication. While dispensing medication, two pills fell on to the medication cart. The nurse picked up the pills and placed them in a medication cup and continued with preparation and administration of medication. The nurse kept the same gloves on to prepare the medication, administer the medication one pill at a time with a spoon, and pick up the resident's water cup for him to drink between each pill. Staff A, LPN removed her gloves but did not perform hand hygiene prior to going to the dining room to get another resident. Staff A, LPN proceeded to gather supplies to check the resident's blood glucose level. The glucometer fell on the floor and Staff A, LPN picked it up and placed it on the medication cart without cleaning it. An observation was conducted on 1/16/25 at 10:08 a.m. while on a tour of C hall. An observation was made of Staff E, Housekeeping (HKG) in Resident #3's room. Resident #3 was in the room and the room door had a Droplet Isolation sign posted, indicating to wear a mask, gown, and gloves at all times and eye protection, if needed. Staff E, HKG was wearing gloves but did not have a mask or gown on while cleaning in Resident #3's room. Staff E, HKG was observed exiting the room while wearing the gloves, pushing the cleaning cart down the hall, picking up a wet floor sign, and re-entering Resident #3's room to continue cleaning. Upon exiting Resident #3's room, Staff E, HKG removed the gloves and exited the room, but no hand hygiene was completed. An interview was conducted with Staff E, HKG on 1/16/25 at 10:15 a.m. Staff E, HKG stated Resident #3's room door had a droplet isolation sign posted and she needed to read the sign to know what PPE to wear. Droplet Isolation would need a gown, gloves and mask. Staff E, HKG stated, I did not, indicating not wearing mask or gown while in Resident #3's room. Staff E, HKG continued to state, I should've washed my hands when I left the room. On 1/16/25 at 10:12 a.m., Staff F, Certified Nursing Assistant (CNA) was observed in room [ROOM NUMBER]. room [ROOM NUMBER] had a Contact Isolation sign posted on the door. The Contact Isolation sign indicated staff must wear gloves and gowns at all times. Staff F, CNA looked around the corner of the privacy curtain, noted the surveyors in the hallway, and closed the curtain. During this time, Staff F, CNA, was observed wearing gloves but no gown. A second person, later identified by the Director of Nursing as a hospice aide, entered room [ROOM NUMBER] with no PPE on. The hospice aide handed a bag of supplies to Staff F, CNA and exited the room without performing hand hygiene. The hospice aide reentered room [ROOM NUMBER] without donning PPE and leaned across the bedside table with her upper body touching the table. Staff F, CNA returned to the door of the room with no gown on, grabbed another pair of gloves, returned to the bedside to pick up a bag of soiled linens, and took the bag to the soiled utility room. The hospice aide remained in the resident room with no gown or gloves on, talking on her cell phone. An interview was conducted on 1/16/25 at 10:25 a.m. with Staff A, LPN. Staff A, LPN said Resident #3 was on Droplet Precautions and room [ROOM NUMBER] was on Contact Precautions. Staff A, LPN also stated Contact Precautions required a gown and gloves whenever going into the room for any reason and Droplet Precautions required gloves, a gown, and a mask when entering the room. An interview was conducted on 1/16/25 at 2:22 p.m. with Staff F, CNA. Staff F, CNA confirmed being assigned to room [ROOM NUMBER], who was on Contact Isolation. Staff F, CNA also stated Contact Isolation required a gown and gloves when entering the room. Staff F, CNA confirmed she took off a gown while in room [ROOM NUMBER], but did not exit the room, and continued to provide care for the resident. An interview was conducted on 1/16/25 at 5:04 p.m. with the DON and ADON/IP. The DON said all staff should be wearing proper PPE when going into a room with a Contact Precaution sign posted. The ADON/IP said, anybody entering a room on Contact Precautions should be wearing the gear. The ADON/IP also said Droplet Precautions required anyone entering the room to wear a blue mask, a gown, gloves, and a face shield. They both stated precautions apply to anyone entering the room, including visitors, contractors, and housekeeping. The ADON/IP said, we educate no gloves in the hallway, and stated they should be removed prior to exiting a room. The DON confirmed the hospice aide should have worn PPE in room [ROOM NUMBER]. The ADON/IP said blood pressure cuffs and glucometers should be sanitized after each use. She explained the glucometer should be wiped with one wipe, then a second wipe should be wrapped around the glucometer and set in a cup for two minutes. She also said if a glucometer falls on the floor it should not be placed on the medication cart prior to cleaning. She said if a pill is dropped on the medication cart, the nurse should dispose of the pill and it should not be picked up and put in the medication cup for administration. The DON said hand hygiene should be done before and after care and should also be done before and after giving medications. She said it does not matter if gloves are worn or not, anytime gloves come off hand hygiene should be done. Review of policy titled Hand Hygiene Infection Control, revised 6/2023, showed: Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: Situations that require hand hygiene include, but are not limited to: - Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). - Before and after entering isolation precaution settings. - Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident). - After removing gloves or aprons. Review of policy titled Transmission Based Precautions, revised 2/2024, showed: All staff receive training on transmission-based precautions upon hire and at least annually. The procedure for Contact Precautions revealed: a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens.

Based on observations, interviews, and record review, the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 11/18/2024 through 11/21/2024 as evidenced by: 1.) failure to provide a safe, clean, and homelike environment for one (B Hall) of two community shower rooms (F584), 2.) failure to ensure blood glucose levels were checked and insulin was administered timely for two residents (#1 and #2) out of three residents reviewed for insulin administration and failed to administer anti-viral medication for one resident (#3) out of one resident reviewed for flu treatment (F684) and 3.) failure to implement an effective Infection Control program as evidenced by staff members not using personal protective equipment (PPE) for two residents (Resident #3 and Resident in room [ROOM NUMBER]) out of 11 on transmission based precautions (TBP) and two out of six residents observed during medication administration (F880). Findings included: Review of the facility's Quality Assurance/Performance Improvement Plan (QAPI), with a revision date February 23, 2021, revealed: Vision To pioneer healthcare by creating a compassionate, memorable and dignified experience for every person we serve. We strive to treat our patients, their families and our staff with the highest level of dignity and respect by promoting an environment of continuous improvement and service excellence. Mission We at [another healthcare facility name] are committed to the physical, emotional and spiritual well-being of our residents. We strive to provide excellent service for residents of every culture in a supportive, caring, homelike environment and to maintain a high level of dignity and individuality. Values Passion: We are strongly compelled to provide great care to every resident we serve. Respect: We feel deep admiration for others and their abilities, qualities and achievements. Integrity: We do the right thing for the right reasons. Dedication: We are committed to providing great care. The staff will utilize data from industry standards to quantify and benchmark all aspects of performance improvement whenever possible. Any negative trends in data will be addressed utilizing root cause analysis and quality improvement methodologies. The leadership and staff will embrace the evidence-based strategies and utilize PDSA cycles until the desired change is effective and the desired goals are achieved and sustained. Governance and Leadership The governing body and/or administration of the nursing home will develop a culture that involves leadership seeking input from facility staff, residents and their families/representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. [Another healthcare facility name] governing body is ultimately responsible for overseeing the QAPI Committee. The owner/CEO has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. A facility-wide training will be conducted to inform everyone in the facility about the QAPI Program. These trainings will be conducted often and in multiple ways through (e.g. in services, department head in services, examples, exercises, etc.) Every caregiver will be made to understand that they are expected to raise quality concerns, that it is safe to do so, and that everyone is encouraged to think about systems. The QAPI approach at [another healthcare facility name] will also be communicated to consultants, contractors and collaborating agencies, to make them understand that they each have a role in the QAPI plan. [another healthcare facility name] will ensure that all residents and families are aware of the facility's QAPI program, and that their views are sought, valued and considered in facility decision-making and process improvements. The QAPI program will be announced and discussed at the resident council meetings, and other resident and family events/venues. Feedback, Data Systems and Monitoring [Another healthcare facility name] will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigation and monitoring events every time they occur, and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences. The QAPI team at [another healthcare facility name] will decide what data to monitor routinely. Areas to consider may include, but not be limited to, the following examples: - Clinical care areas (e.g. pressure ulcers, falls, infections) - Medications (e.g., those that require close monitoring, antipsychotics, narcotics) - Complaints/grievances from residents and families - Hospitalizations and other service use - Resident satisfaction - Caregiver satisfaction - Care plans, including ensuring implementation and evaluation of measurable interventions - State survey results and deficiencies - Results from MDS resident assessments - Business and administrative processes (e.g., financial information, caregiver turnover, caregiver competencies and staffing patterns, such as permanent caregiver assignment). Data related to caregivers who call out sick or unable to report to work on short notice, caregiver injuries and compensation claims may also be useful. Targets for performance in the areas that are being monitored will be set by the QAPI team. The target will usually be stated as a percentage. Benchmarks for performance such as Nursing Home Compare (www.medicare.gov/nhcompare), CASPER report, Facility Inhouse Benchmarking, etc. will be used to monitor facility progress. Performance Improvement Projects (PIP) The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment. In addition, the QAPI Steering Committee will implement any PIP topics indicated by date analysis. Quality improvement activities are also developed in collaboration with the support of providers, residents, families and staff. PIPS are implemented in accordance with CMS' protocol for conducting PIPS, including: 1. Measurement of performance using objective quality objective indicators 2. Implementation of system interventions to achieve improvement in quality 3. Evaluation of the effectiveness of the interventions 4. Plan and initiation of activities for increasing or sustaining improvement During an interview on 1/16/2025 at 5:55 p.m., the Nursing Home Administrator (NHA) stated the Quality Assurance (QA) Committee includes himself, the Medical Director, the Director of Nursing (DON), and other department heads. The NHA said he was the Committee Chairperson and the QA Committee meets on the third Thursday of every month, although they have not met this month. The NHA stated a QAPI meeting was conducted on 12/18/2024 to discuss the survey results and plan of correction that was submitted to the State Agency. The NHA stated the facility did not conduct another QAPI meeting in January, even though the third Thursday had past, but then stated, the month is not over yet, we will have one. The NHA stated during the meeting in December, they spent the entire meeting on going over the 2567 and developed action plans based on the situations referenced in the survey. 1.) On 1/16/2025 at 9:58 a.m., the shower room on B hall was observed with a housekeeping employee packing up their supplies, placing a wet floor sign at the door, and about to exit the room. A shower bed was observed in the room. Upon lifting the foam mat sitting on top of the mesh of the shower bed, the back of the foam mat had unidentifiable black spots and various clumps of hair covering almost the entire middle section. The mesh part of the bed was observed with dried brown, black, and white stains on the majority of the mesh. Next to the shower bed was a shower chair. The chair was observed with brown/black substance with hair clumps intermingled on all four shower legs above the wheels. At the joints of the four legs was a pink colored substance above and below the joints. The mesh backing of the shower chair had a buildup of a black substance on all three straps. During an interview on 1/16/2025 at 5:55 p.m., the NHA and DON stated nursing and housekeeping are responsible for cleaning the shower rooms. The NHA and DON reviewed the photos of the shower room on B hall and acknowledged the equipment was dirty. 2.) An observation was conducted during medication administration on 1/16/25 at 12:05 p.m. with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN was preparing to administer medication to Resident #1 and had to go to the dining room to get the resident to check his blood glucose level and administer insulin. Resident #1 said he had already finished eating lunch. He said the nurses often check his blood glucose after meals and not before, they are usually late. Staff A, LPN checked Resident #1's blood glucose and it was observed to be 309. The nurse told the resident she was going to administer 15 units of Humalog insulin. Staff A, LPN was observed priming the Humalog insulin pen and setting it to 15 units. The resident refused the 15 units of insulin, saying his blood glucose level would drop too low if he had that much. The nurse called the doctor and received a one-time order for 10 units of Humalog insulin, which was administered at 12:24 p.m. Review of the admission Record showed Resident #1 was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus (DM) with hypoglycemia. Review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Review of Resident #1's January 2025 physician orders showed the following orders: - Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (units per milliliter) (Insulin Lispro). Inject 15 unit subcutaneously in the morning for DM. Scheduled for 9:00 a.m. Dated 12/8/24. - Insulin Lispro (1 unit dial) 100 unit/ml solution pen-injector. Inject as per sliding scale. Scheduled at 7:05 a.m., 11:30 a.m., and 4:30 p.m. Dated 4/12/24. Review of the Medication Admin Audit Report from 1/2/25 to 1/16/25 showed Resident #1's Humalog was administered late on 7 of 14 opportunities. Resident #1's Insulin Lispro was administered late on 23 of 42 opportunities. An interview was conducted on 1/16/25 at 5:50 p.m. with Staff C, LPN. She said at the time of the interview, all meals had been delivered to residents. Therefore, all blood glucose checks should have been done, because those should be checked prior to eating. An observation and interview was conducted during medication administration on 1/16/25 at 5:57 p.m. with Staff B, LPN. Staff B, LPN was preparing to administer medication to Resident #2. Staff B, LPN was observed entering Resident #2's room to check her blood glucose level. The resident was already eating her dinner at the time. Staff B, LPN confirmed blood glucose levels should be checked prior to meals. Review of the admission Record showed Resident #2 was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus with neuropathy. Review of Resident #2's January 2025 physician orders showed the following orders: - Insulin Lispro (1 unit dial) Subcutaneous solution pen-injector 100 unit/ml. Inject per sliding scale for times a day for DM. Dated 10/28/24. Scheduled times were 6:00 a.m., 12:00 p.m., 2:00 p.m., and 10:00 p.m. The order times changed on 1/10/25 to 6:00 a.m., 12:00 p.m., 5:00 p.m., and 10:00 p.m. - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ml. Inject 12 units subcutaneously one time a day for DM. Dated 10/28/24. Scheduled at 9:00 a.m. Review of the Medication Admin Audit Report from 1/2/25 to 1/16/25 showed Resident #2's Insulin Lispro was administered late 2 times, early 3 times, and not administered 6 times out of 56 opportunities. Insulin Glargine was administered late 5 out of 14 opportunities. An interview was conducted on 1/16/25 at 6:20 p.m. with the DON. The DON reviewed Resident #1's record and confirmed the resident's blood glucose level should have been checked between 8:00-10:00 a.m. and the Humalog should have been administered then. She said the Humalog was scheduled at 9:00 a.m. for Resident #1. She also said typically when a nurse is running behind, herself or the unit managers jump in to help. The DON said blood glucose levels should be checked before a resident eats their meals and the insulin should be given at mealtime. An observation was conducted on 1/16/25 at 9:25 a.m. of Resident #3's room with a droplet precautions sign hanging on the door. Review of the admission Record showed Resident #3 was admitted on [DATE] with diagnoses including chronic pulmonary edema and dementia. Review of Resident #3's care plan showed a Focus of The resident has infection: flu exposure, initiated 1/11/25. Interventions included droplet precautions, administer anti-viral per MD (medical doctor) orders, and administer treatment per physician orders. Review of Resident #3's January 2025 physician orders showed an order for: - Tamiflu Oral Capsule 75 mg (milligrams). Give 1 capsule by mouth two times a day for exposure to flu for 5 days. Start date 1/13/25. Discontinue date 1/18/25. Review of Resident #3's Medication Administration Record (MAR) for January 2025 showed Tamiflu was not available for the 9:00 a.m. dose on 1/13/25. Tamiflu was signed off as given on 1/13/25 at 9:00 p.m., 1/14/25 at 9:00 a.m. and 9:00 p.m., and 1/15/25 at 9:00 a.m. and 9:00 p.m., and marked not available at 9:00 a.m. on 1/16/25. An interview was conducted on 1/16/25 at 4:55 p.m. with Staff D, Registered Nurse (RN). Staff D, RN said he was assigned to Resident #3. He checked the medication cart and said there was no Tamiflu in the medication cart for Resident #3. An interview was conducted on 1/16/25 at 5:10 p.m. with a representative from the facility's pharmacy. The pharmacy said no Tamiflu was dispensed for Resident #3. An interview was conducted on 1/16/25 at 5:04 p.m. with the DON and Assistant Director of Nursing/Infection Preventionist (ADON/IP). They both reviewed Resident #3's medical record. The DON said she would not expect the Tamiflu to be signed off since it was not given. She said it should have been documented the medication was not administered and the doctor should have been called. The ADON/IP said she did not see any notes in Resident #3's medical record indicating the doctor was notified the Tamiflu was not given or was not available. The DON confirmed there were no notes in the record. Review of a facility policy titled Standards and Guidelines: Medication Administration, with a revision date of 01/2024 revealed the following: Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber's orders, including any required time frame. 6. Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime). 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering shall document the rationale in the resident's medical record and notify the physician and responsible party if indicated. 3.) An observation was conducted on 1/16/25 at 9:34 a.m. during medication administration with Staff G, LPN. Staff G, LPN was observed completing medication administration for a resident without performing hand hygiene. She began preparing medication for a second resident, entered the second resident's room, and took vital signs. Staff G, LPN exited the room, placing the blood pressure cuff on the medication cart prior to cleaning it. Staff G, LPN put on gloves and cleaned the blood pressure cuff, removed the gloves, and did not perform hand hygiene before continued to prepare and administer medication for the resident. An observation was conducted on 1/16/25 at 11:55 p.m. during medication administration with Staff A, LPN. Staff A, LPN was observed wearing gloves to prepare medication. While dispensing medication, two pills fell onto the medication cart. The nurse picked up the pills and placed them in a medication cup and continued with preparation and administration of medication. The nurse kept the same gloves on to prepare the medication, administer the medication one pill at a time with a spoon, and pick up the resident's water cup for him to drink between each pill. Staff A, LPN removed her gloves but did not perform hand hygiene prior to going to the dining room to get another resident. Staff A, LPN proceeded to gather supplies to check the resident's blood glucose level. The glucometer fell on the floor and Staff A, LPN picked it up and placed it on the medication cart without cleaning it. An observation was conducted on 1/16/25 at 10:08 a.m. while on a tour of C hall. An observation was made of Staff E, Housekeeping (HKG) in Resident #3's room. Resident #3 was in the room and the room door had a Droplet Isolation sign posted, indicating to wear a mask, gown, and gloves at all times and eye protection, if needed. Staff E, HKG was wearing gloves but did not have a mask or gown on while cleaning in Resident #3's room. Staff E, HKG was observed exiting the room while wearing the gloves, pushing the cleaning cart down the hall, picking up a wet floor sign, and re-entering Resident #3's room to continue cleaning. Upon exiting Resident #3's room, Staff E, HKG removed the gloves and exited the room, but no hand hygiene was completed. An interview was conducted with Staff E, HKG on 1/16/25 at 10:15 a.m. Staff E, HKG stated Resident #3's room door had a droplet isolation sign posted and she needed to read the sign to know what PPE to wear. Droplet Isolation would need a gown, gloves and mask. Staff E, HKG stated, I did not, indicating not wearing mask or gown while in Resident #3's room. Staff E, HKG continued to state, I should've washed my hands when I left the room. On 1/16/25 at 10:12 a.m., Staff F, Certified Nursing Assistant (CNA) was observed in room [ROOM NUMBER]. room [ROOM NUMBER] had a Contact Isolation sign posted on the door. The Contact Isolation sign indicated staff must wear gloves and gowns at all times. Staff F, CNA looked around the corner of the privacy curtain, noted the surveyors in the hallway, and closed the curtain. During this time, Staff F, CNA, was observed wearing gloves but no gown. A second person, later identified by the Director of Nursing as a hospice aide, entered room [ROOM NUMBER] with no PPE on. The hospice aide handed a bag of supplies to Staff F, CNA and exited the room without performing hand hygiene. The hospice aide reentered room [ROOM NUMBER] without donning PPE and leaned across the bedside table with her upper body touching the table. Staff F, CNA returned to the door of the room with no gown on, grabbed another pair of gloves, returned to the bedside to pick up a bag of soiled linens, and took the bag to the soiled utility room. The hospice aide remained in the resident room with no gown or gloves on, talking on her cell phone. An interview was conducted on 1/16/25 at 10:25 a.m. with Staff A, LPN. Staff A, LPN said Resident #3 was on Droplet Precautions and room [ROOM NUMBER] was on Contact Precautions. Staff A, LPN also stated Contact Precautions required a gown and gloves whenever going into the room for any reason and Droplet Precautions required gloves, a gown, and a mask when entering the room. An interview was conducted on 1/16/25 at 2:22 p.m. with Staff F, CNA. Staff F, CNA confirmed being assigned to room [ROOM NUMBER], who was on Contact Isolation. Staff F, CNA also stated Contact Isolation required a gown and gloves when entering the room. Staff F, CNA confirmed she took off a gown while in room [ROOM NUMBER], but did not exit the room, and continued to provide care for the resident. An interview was conducted on 1/16/25 at 5:04 p.m. with the DON and ADON/IP. The DON said all staff should be wearing proper PPE when going into a room with a Contact Precaution sign posted. The ADON/IP said, anybody entering a room on Contact Precautions should be wearing the gear. The ADON/IP also said Droplet Precautions required anyone entering the room to wear a blue mask, a gown, gloves, and a face shield. They both stated precautions apply to anyone entering the room, including visitors, contractors, and housekeeping. The ADON/IP said, we educate no gloves in the hallway, and stated they should be removed prior to exiting a room. The DON confirmed the hospice aide should have worn PPE in room [ROOM NUMBER]. The ADON/IP said blood pressure cuffs and glucometers should be sanitized after each use. She explained the glucometer should be wiped with one wipe, then a second wipe should be wrapped around the glucometer and set in a cup for two minutes. She also said if a glucometer falls on the floor it should not be placed on the medication cart prior to cleaning. She said if a pill is dropped on the medication cart, the nurse should dispose of the pill and it should not be picked up and put in the medication cup for administration. The DON said hand hygiene should be done before and after care and should also be done before and after giving medications. She said it does not matter if gloves are worn or not, anytime gloves come off hand hygiene should be done. Review of policy titled Hand Hygiene Infection Control, revised 6/2023, showed: Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: Situations that require hand hygiene include, but are not limited to: - Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). - Before and after entering isolation precaution settings. - Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident). - After removing gloves or aprons. Review of policy titled Transmission Based Precautions, revised 2/2024, showed: All staff receive training on transmission-based precautions upon hire and at least annually. The procedure for Contact Precautions revealed: a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens.

Based on observation, interview, and medical record review, the facility failed to ensure call light cords and buttons were placed within reach for three (#61, #34, and #24) of forty-eight sampled residents. Findings included: 1. On 11/18/2024 at 2:10 p.m., 11/19/2024 at 8:10 a.m., 3:20 p.m., and on 11/20/2024 at 8:02 a.m. and 9:52 a.m., while Resident #61 was visited in her room, she was observed each time lying in bed flat, under the covers and receiving services to include nourishment via a tube feed system, pressure ulcer care via a wound vacuum system, and also was observed utilizing an indwelling urinary catheter. Further observations revealed each visit included the call light button and cord was either placed hanging off the back of the head of the mattress and between the wall out from her reach or lying on the floor out from her reach. An initial interview attempt was made with Resident #61 on 11/18/2024 at 2:10 p.m., she was noted with cognitive deficits. Resident #61 was able to speak related to her daily routines and simple questions related to her care. Resident #61 said that she called staff for help almost every day. She was asked how she called for staff. She said she tried to use the call light and was observed looking for it. She could not find the call light button and revealed there were times the staff did not put it where she could find it. It was observed at that time to be back and behind her pillow/mattress and between the mattress and the wall, hanging down approximately two feet, well away from Resident #61's reach. Resident #61 could not see the call light button and said she would not be able to locate it and use it if it was behind her and hanging down. Resident #61 was noted in a private room and most of the day she had the door closed. Resident #61 revealed there were times when she could not find her call light button and there were times she had to yell out but staff did not hear her. She said she had mentioned to staff to please place the call light within her reach all the time, but this did not happen all the time. She had spoken to her nurses, (no names given or timeframes), but things had not gotten better. Review of the electronic medical record to include nurse progress notes dated from 10/17/2024 to current review date 11/21/2024, did not reveal any documentation to support Resident #61 had behaviors of tossing, or throwing the call light button away from her. There was no documentation to support Resident #61 did not use her call light. Progress note dated 11/19/2024 18:20 (6:20 p.m.) revealed Resident #61 was observed resting in bed and with the call light placed within her reach. This note supported staff are to place the call light within her reach when she was in bed. Review of the current Admission Minimum Data Set (MDS) assessment dated [DATE], showed: Cognition or Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment; Mood - none documented as observed during timeframe; Behavior - None documented as observed during timeframe; ADL (Activities of Daily Living) - Shower/Bathing including washing, rinsing, and drying self - Substantial/Maximal assistance; Personal Hygiene-the ability to maintain personal hygiene including combing hair, shaving, apply make up, washing/drying hands - Substantial/Maximal assistance. The MDS assessment Showed Resident #61 required maximum assistance with most of her care and services. Review of the current care plans with next review date 1/18/2025 revealed the following but not limited to areas: 1. Risk for falls related to impaired mobility, cognitive impairment with interventions to include but not limited to: Encourage and remind the resident to use the call bell. On 11/20/2024 at 9:55 a.m., an interview with Staff A, Certified Nursing Assistant (CNA), revealed all residents in the building were to have their call light placed within their reach whether they were in bed, or seated in a chair or wheelchair in their room. Staff A confirmed Resident #61 used the call light at times to get staff assistance. Staff A confirmed at 9:55 a.m., the call light was not placed within Resident #61's reach. Staff A said Resident #61 would toss the call light away, but she had not reported that to any nurses in the past. On 11/20/2024 at 10:03 a.m., an interview with Staff B, Licensed Practical Nurse (LPN), Station 1 Unit Manager, revealed she knew Resident #61 and that she required maximum assistance with all her ADL. She further confirmed Resident #61 used the call light button to get staff assistance. Staff B confirmed all residents were to always have their call light button placed within their reach when they were in their rooms and while in bed. Staff B. revealed she had not been made aware from any staff that Resident #61 threw or tossed the call light button away from her, nor could she find documentation in the electronic record to support that. On 11/21/204 at 7:50 a.m., an interview with Staff C, LPN, who was Resident #61's assigned nurse, revealed all residents were to have their call light buttons placed within their reach when they were in their rooms and in bed. Staff C could not remember a time when Resident #61 threw or tossed her call light button on the floor. Staff C verified the resident often used the call light to call for assistance. Staff C could not show in the medical record that Resident #61 had behaviors of displacing the call light button out of her reach. On 11/21/2024 at 7:56 a.m., an interview with Staff D, CNA revealed she did not know the resident well as she floated around the facility. She confirmed she had the resident on her assignment today and she had seen her already. Staff D confirmed that all residents when in bed and if seated in chairs next to their bed, should have call lights placed within their reach. Staff D was not aware of the resident throwing or tossing the call light button out of her reach. She revealed if that were the case, and for every resident, they would report that behavior to the nurse or Director of Nursing. Staff D revealed she had been trained and inserviced to go in the room and look for things related to comfort and safety, and call light placement is one of those things she looks out for. 37999 2. On 11/18/24 at 10:59 a.m., Resident #34 was observed sitting in a wheelchair between the bed and the wall next to the bathroom. The resident's call light pad was observed on the other side of the bed. On 11/19/24 at 10:02 a.m., Resident #34 was observed lying in bed. The resident's call light pad was observed lying next to the left hip of the resident's roommate and another call light button was hanging on the top of the roommate's mattress. Neither of the room's call light devices were accessible to Resident #34. On 11/19/24 at 10:12 a.m. the Director of Nursing (DON) observed Resident #34 lying on her left side with her right foot hanging out of bed, facing the bathroom wall. The DON moved the folded floor mat to the left side of bed. She reported Resident #34 was able to use the call light and confirmed the resident's call light pad was on the roommate's bed. On 11/20/24 at 8:46 a.m., an unknown staff member was observed assisting Resident #34 with eating the morning meal while the resident was sitting in wheelchair between the bed and the bathroom wall. On 11/20/24 at 9:00 a.m., Resident #34 was observed sitting in a wheelchair in between the bed and the bathroom wall. The resident's call light pad location was unknown and not seen within the resident's reach. On 11/20/24 at 9:03 a.m., Staff L, Certified Nursing Assistant (CNA) located the resident's call light pad behind the floor mat that was in front of the bedside dresser between the bed and the curtain separating the resident's and roommate's beds. The staff member stated the resident must have dropped it. Staff L stated the staff member who had been assisting the resident with eating should have ensured the call light was within reach of the resident prior to leaving the resident. Review of Resident #34's care plan revealed the resident was at risk for falls related to (r/t) cognitive deficit, history of falls, impaired vision, (and) use of anti-hypertensive medications. The related interventions included but not limited to encourage and remind resident to use call bell to wait for staff assistance with transfers, ambulation, toileting, etcetera (etc.) as tolerated, initiated on 10/4/22. 3. On 11/19/24 at 10:05 am., Resident #24 was observed lying in bed with the head of bed slightly raised. The observation showed the resident's call light button was hanging through the resident's raised bed rail and lying against the bedside dresser. The call light was not within reach of the resident. On 11/19/24 at 10:09 a.m., Resident #24 was observed with the Director of Nursing (DON). The DON viewed the resident's call light and stated it must have fallen and reported the resident was unable to use the call light. Review of resident #24's care plan revealed the resident was at risk for falls related to (R/T) history of falls, unsteady gait/ poor balance, use of anti-hypertensive medications. This focus was initiated and revised on 1/16/23. The interventions showed that nursing staff should Encourage and remind resident to use call bell and to wait for staff assistance with transfers, ambulation, toileting, etcetera (etc.) as indicated. Review of the policy - Call lights, revised 1/2024, showed the standard was the Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. The guideline was Resident's call light is to be within reach and answered promptly by facility personnel. The procedure instructed: 1. Answer call light promptly. All Facility personnel are expected to respond to call lights. 2. Knock on the room door, announce yourself, and be courteous when entering the room. 3. Turn off the call light. 4. Listen to residents' request. DO NOT Make residents feel that you are too busy. (#5 is missing from the policy) 6. Office services before leaving the resident's room. Insure the call light is within reach. 7. If the call light is defective, report to maintenance. 8. Call lights must remain functional and within reach of each resident. Call lights must not be disabled. Call lights shall not be removed from resident's reach unless this is a therapeutic intervention documented in a resident specific behavior management plan set forth by the physician and/ or mental health clinician in response to problematic and/for attention seeking behavior. 9. Respond to the residents' request, if unable to assist, notify the nurse. Return to the resident promptly with a reply.

Based on observation and interview, the facility failed to ensure a clean and comfortable environment by not maintaining and cleaning one (B Hall) of two community shower rooms. Findings included: On 11/18/2024 at 9:40 a.m., an observation was made of the B Hall community shower room. Upon entering the shower room, it was observed to be cluttered and disorganized. Located on the left-hand side just after entry was a restroom with a toilet and sink. Next to the room with the toilet, there was a shower with a curtain. On the other side of the room there were two sinks. The clutter of the room made it hard to get to the other two sinks. The clutter observed included a privacy curtain, various wheelchair parts, Hoyer lift, bedside commode and a walker. (Photographic evidence obtained). The observation of the shower room also included: 1. The foam mat laying on the top of the shower bed had a dried brown substance on the top. 2. On the shower bed underneath the foam mat and on the mesh part of the bed, there were dried brown and black objects as well as hair. 3. In a corner of the room there was a trash bucket; the lid was sitting on the floor next to the trash bucket; inside the trash bucket there were soiled gloves. The lining of the trash bucket was soiled with a brown substance. 4. The Hoyer lift pad, which was placed on the Hoyer lift, was soiled with a brown substance. 5. The grout in the shower was dirty with a black-brown substance. 6. Next to the entry door of the shower room there was a clump of hair on the wall. 7. The Hoyer lift itself had dirt, dust and a dried brown substance on it. 8. Trash and wheelchair attachments were on the floor. 9. A dirty band aid on the floor of the shower. 10. Hair on the shower floor. 11. Ripped and stained shower curtains. On 11/19/2024 at 9:33 a.m., an observation was made of the B Hall community shower. The observation was the same as the previous day's observation with no cleaning or organizing having been done. An interview was conducted on 11/20/2024 at 3:00 p.m. with Staff H, Director of Environmental Services. The Environmental Services Department includes the Housekeeping Department. He said a housekeeper starts the day at 7:00 a.m. cleaning the front lobby and the offices. The other housekeeping staff work from 9:00 a.m.-5:30 p.m. Staff H, Director of Environmental Services, said the housekeepers were assigned unit halls and were expected to clean the hallways, resident rooms, nurses' stations, and shower rooms. He said the shower rooms were cleaned once per day. Before entering the shower room Staff H, Director of Environmental Services, said he had not seen the current condition of the room. He said housekeeping responsibilities for cleaning the shower rooms include cleaning the floors, walls, toilets and sinks. He said he expected the shower rooms should be cleaned by 10:00 a.m. every day. He said curtains, which include resident rooms and the shower rooms, were checked one unit hall per week and replaced or cleaned if they are dirty. He agreed the curtains in the shower room needed to be changed. He also agreed the shower room did not look clean, appealing or organized. He said in the shower rooms the Certified Nursing Assistants who gave resident showers were responsible for picking up any dirty linen, cleaning up any bodily fluids, cleaning the equipment, and disinfecting the area(s) used while giving resident showers. During an interview on 11/21/2024 at 2:47 p.m., Staff W, CNA said it was the CNA's responsibility in the shower room to clean up after themselves after showering a resident. She said the CNA's were to pick up any dirty linen or towels, clean the shower area, disinfect and clean any equipment that was used during the resident's shower. Staff W said they were really busy and did the best they could to clean everything up as fast as possible. She said if another CNA did not clean up after showering a resident, she would tell the other CNA to clean it up and if it did not get done she could report it to the manager. During an interview on 11/21/2024 at 3:00 p.m. with the Nursing Home Administrator (NHA), he said he was not aware of the issues in the shower room. He said he had not been in the shower rooms lately. The NHA said he would talk to Staff H, Director of Environmental Services and get the shower rooms cleaned and organized. Review of the General Cleaning Policies and Procedures Resident Room - Clean, which was not dated, was provided by the Staff H, Director of Environmental Services, did not reveal specific guidance for cleaning the community shower rooms.

Based on observation, interview, and record review, the facility failed to ensure one (#61) of forty-eight sampled residents, was provided with personal hygiene fingernail care during at least three of four days observed (11/18/2024, 11/19/2024, 11/20/2024). It was observed all ten of the fingernails were found with dark debris and were long, cracked/chipped and leaving sharp edges. Findings included: On 11/18/2024 at 2:10 p.m., Resident #61 was visited while in her room. She was observed residing in a private room and was noted in her bed lying flat with the Head of Bed (HOB) approximately 30 degrees. Resident #61 was further observed with her hands placed on her lap, over the bed linen. All ten fingernails were observed elongated approximately 1/2 inch to 3/4 inches, cracked and chipped with sharp edges. Further, the under nails were observed with build up of dark debris/matter. An interview with Resident #61 revealed she had impaired cognition, but was able to speak with regards to her daily routines and she was able to speak related to her personal hygiene and nail care. Resident #61 confirmed her nails were too long and that they had sharp edges. She did not know what all the debris was, which was packed under her finger nails. She confirmed she did not like her nails long, did not like them chipped and did not like having debris/matter under her fingernails. Resident #61 revealed she had asked staff to clip her fingernails in the past and at least three times since her admission. She could not remember which Certified Nursing Assistant (CNA) she told, but she remembered she had spoken to several of them. Resident #61 revealed that each time she had asked for nail care in the past, the CNA's would just tell her they would get to it, but they never did. Resident #61 revealed she did receive showers during her scheduled shower days, and she did not refuse showers or personal hygiene care. On 11/19/2024 at 8:10 a.m., 3:20 p.m., 11/20/2024 at 8:02 a.m., 9:52 a.m., 2:00 p.m., Resident #61 was visited in her room. She presented both of her hands for observation and it was revealed all ten fingernails were still elongated, cracked, chipped and still with dark debris under her nails. Resident #61 revealed she did ask about nail care during the evening shift on 11/20/2024 but staff never came back to do it. She could not remember what staff member she spoke with. .On 11/20 at 9:55 a.m Staff A, who was Resident #61's assigned CNA, was interviewed with relation to personal hygiene and nail care. Staff A revealed Resident #61 required full staff assistance with personal hygiene including showers/baths and nail care. Staff A, also revealed the resident was provided with a bed bath yesterday and she would typically want bed baths. Staff A revealed she usually would scrub the resident's fingers and finger nails to get debris out but was unaware her finger nails were long, cracked and chipped and with debris under the nails. Staff A went in Resident #61's room and confirmed the nails needed care to include clipping and cleaning. Staff A confirmed that as part of their routine daily assignment, they were to look at the resident's personal hygiene to include fingernails. She revealed staff should recognize if nails needed to be clipped and cleaned. Staff A revealed if a resident was diabetic, usually the nurse would be the one to clip the nails. On 11/20/2024 at 10:03 a.m., an interview with Staff B., who was the Station 1 Unit Manager, revealed Resident #61 was a newer admission and at the facility less than one month. Staff B was aware the resident required maximal assistance with her Activities of Daily Living (ADLs) to include shower/bath and personal hygiene. Staff B explained that she was not aware the resident wanted nail care, but at the very least CNAs should have observed her for the need of nail care and/or cleaning. Review of the current Physician's Order Sheet for the month 11/2024 showed the following but not limited to: a. Weekly skin checks every Tuesday during day shift with an order date of 10/22/2024. Review of the nurse progress notes dated from 10/17/2024 to current 11/20/2024 showed no behaviors of refusing personal hygiene to include nail care. Review of the Admission Minimum Data Set (MDS) assessment and dated 10/24/2024, showed Cognition/Brief Interview Mental Status or BIMS score - 5 which indicted severe cognitive impairment; Mood - none documented as observed during the assessment timeframe; Behavior - None documented as observed during the assessment timeframe; ADL - Shower/Bathing including washing, rinsing, and drying self - Substantial/Maximal assistance; Personal Hygiene the ability to maintain personal hygiene including combing hair, shaving, apply make up, washing/drying hands - Substantial/Maximal assistance. Review of the Restorative Nursing Program Initial Evaluation dated 11/11/2024 revealed: Section#1 Assessment/Evaluation diagnosis - Need for Assistance with Personal Care, Weakness. A. Restorative Nursing Program for bed mobility and goal to include: Static and dynamic sitting and standing balance for carryover with ADL tasks to prevent contracture. Review of the current Care Plans with a next review date 1/18/2025 showed the following areas: (a) ADL self care deficit related to activity tolerance ADL needs and participation vary, Limited Mobility with interventions in place to include but not limited to: Extensive Assist for ADL care this may fluctuate with weakness, fatigue and weight bearing status; On 11/21/2024 at 9:47 a.m., the Director of Nursing (DON) was interviewed. She was knowledgeable with regards to Resident #61 and with her daily care and services. The DON revealed the resident had cognition deficits and required maximum assistance with all her Activities of Daily Living (ADL) to include personal hygiene. The DON revealed she was made aware yesterday, 11/20/2024, the resident required finger nail cleaning and trimming and made sure it was completed. The DON revealed it was the expectation of the aide and nurse who were assigned to the resident to look for personal hygiene needs to include nail care, on a daily basis. Review of the ADL Care and Services policy and procedure, with a last revision date of 1/2024 showed the following. The Policy Standard revealed; Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The Guidelines section of this policy revealed; Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Procedure section of this policy revealed; 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, nail care and oral care); 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on observation, staff interview, and medical record review, the facility failed to ensure one (#36) of forty-eight sampled residents was offered and assisted to scheduled activities that met his interest. Findings included: On 11/18/2024 at 9:55 a.m., 10:30 a.m., 1:00 p.m., 2:00 p.m.; on 11/19/2024 at 7:30 a.m., 8:20 a.m., 1:00 p.m., 3:00 p.m.; on 11/20/2024 at 8:07 a.m., 10:00 a.m., 11:30 a.m., 12:21 p.m., 1:45 p.m., 2:00 p.m., 3:00 p.m.; and on 11/21/2024 at 8:00 a.m., 10:00 a.m., and 11:45 a.m., Resident #36 was observed in his room, lying flat in his bed with the covers and blanket over him, pulled over, and above his head. When attempting to meet with Resident #36 on 11/18/2024, he did not respond to an interview. During all the dates and times listed above, Resident #36 was observed not up for the day and not dressed. He was also not observed offered or assisted by either his assigned Certified Nursing Assistants (CNAs) or activities staff with the daily scheduled activities. Review of the large posted current month's (11/2024) activities calendar, posted on the wall across from each nurse station, revealed Resident #36 was not offered or assisted with the following posted activities during the 7 a.m. to 3 p.m. shift on 11/18/2024, 11/19/2024, 11/20/2024, and 11/21/2024: 1. On 11/1/24 - Friendly Visits at 9:30 a.m., Movie time at 2:30 p.m. 2. On 11/3/24 - Streaming Religious/Church services at 10:30 a.m., Outdoor visits at 1:00 p.m. 3. On 11/4/24 - Friendly Visits at 9:30 a.m. 4. On 11/5/24 - Friendly Visits at 9:30 a.m., Men's group at 1:30 p.m. 5. On 11/6/24 - Friendly Visits at 9:30 a.m., Therapy Dog visit at 10:30 a.m. 6. On 11/7/24 - Friendly Visits at 9:30 a.m. 7. On 11/8/24 - Friendly Visits at 9:30 a.m., Courtside with Friends, Movie time at 10:30 a.m. 8. On 11/10/24 - Streaming Religious/Church services at 10:30 a.m., Outdoor visits at 1:00 p.m. 9. On 11/11/24 - Friendly Visits at 9:30 a.m., Bible study at 1:30 p.m. 10. On 11/12/24 - Friendly Visits at 9:30 a.m., Musical moment at 10:30 a.m., Men's group at 1:30 p.m. 11. On 11/13/24 - Friendly Visits at 9:30 a.m., Therapy dog visit at 10:30 a.m. 12. On 11/14/24 - Friendly Visits at 9:30 a.m., Ice Cream Social at 2:30 p.m. 13. On 11/15/24 - Friendly Visits at 9:30 a.m., Movie time at 2:30 p.m. 14. On 11/17/24 - Streaming Religious/Church services at 10:30 a.m., Outdoor visits at 1:00 p.m. 15. On 11/18/24 - Friendly Visits at 9:30 a.m., Stretching with friends at 10:30 a.m. 16. On 11/19/24 - Friendly Visits at 9:30 a.m., Men's group at 1:30 p.m. 17. On 11/20/24 - Friendly Visits 9:30 a.m., Therapy dog visit at 10:30 a.m. 18. On 11/21/24 - Friendly Visits at 9:30 a.m., Apple cider social at 2:30 p.m. It was found through review of the medical record, Resident #36 was documented as somewhat interested related to the above listed activities. Further, there was no documentation to support whether he was either offered or assisted to any of them nor was there any documented evidence he refused any of these activities. Review of Resident #36's nurse progress notes and activities notes dated from 6/1/2024 through to 11/21/2024 did not reveal Resident #36 refused to go to activities both group and individual. Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the following: Cognition/Brief Interview Mental Status BIMS score - 00 of 15, which indicated Resident #36 was not interviewable and not able to speak related to his daily care and services; Mood - None documented as observed during the assessed timeframe; Behaviors - None documented as observed during the assessed timeframe; Activities/Preference - This section was not completed. Review of Resident #36's Annual MDS assessment dated [DATE], revealed: Activities/Preferences = A. How important is it to you to have books, etc. = Somewhat Important; How important is it to you to listen to music you like = Somewhat Important; How important is it to you to be around animals such as pets = Somewhat Important; How important is it to you to keep up with the news = Somewhat Important; How important is it to you to do things with groups of people = Somewhat Important; How important is it to you to do your favorite activities = Somewhat Important; How important is it to you to go outside to get fresh air when the weather is good = Somewhat Important; How important is it to you to participate in religious service practices = Somewhat Important. Review of Resident #36's Lifestyle & Activity preference evaluation dated 7/15/2022 revealed: Section C; Leisure Preferences = Yes to Entertainment television, music, movies, Yes Catholic activities. Review of the Lifestyle & Activity preference evaluation dated 1/11/2023 revealed: Section C; Leisure Preferences = Yes to Entertainment television, music, movies, Yes Catholic activities. Review of Resident #36's Quarterly Activity Progress notes dated 9/18/2023 revealed; Summary - Resident enjoys a variety of activities including friendly visits from select staff and peers, being read to, listening to music, compassionate touch, listening to the TV. Review of Resident #36's Quarterly Activity Progress notes dated 12/21/2023, revealed; Summary - Resident enjoys watching television and listening to music. Preferably Hispanic program. Review of Resident #36's Quarterly Activity Progress notes dated 3/15/2024, revealed; 1:1 visits provided by staff #3. Notes - Resident enjoys watching television, listening to music, and visiting with select staff members. Resident expresses satisfaction and staff will continue to provide 1:1 visits. Review of Resident #36's most current Lifestyle & Activity preference evaluation dated 6/21/2024, revealed: Section C. Leisure Preferences - Resident enjoys friendly visits and having books read to him. Resident enjoys watching television and listening to music. Review of Resident #36's current Care Plans with next review date 12/16/2024 revealed the following: (a) Resident is receiving palliative care/Hospice services receiving hospice services with diagnosis Cellulitis of perineum. Interventions in place to include but not limited to: Collaborate with hospice team to ensure the resident's spiritual emotional intellectual and physical and social needs are addressed, Assess resident's coping strategies as needed and respect resident wishes. (b) Resident has potential for little or no activity involvement related to visual impairment, impaired cognitive function/impaired balance. Often remains in bed for comfort/preference with interventions in place to include but limited to: 1. Educate the resident on the importance of social interaction and leisure activity time; 2. Encourage participation in activities of potential interest; 3. Invite/encourage the resident's family members to attend activities with the resident as needed/desired; 4. Offer friendly visits to promote independent leisure past times and socialization; 5. Provide resident 1:1 or bedside activities as needed for support and socialization/stimulation; 6. Remind the resident that the resident may leave activities at any time, and is not required to stay for entire activity; 7. Resident requires specific interventions i.e. cueing and reminders to engage in activities of interest; 8. Resident will benefit from small groups to include sensory, listening to music; 9. Resident needs assistance/escort to activity functions. On 11/21/2024 at 9:48 a.m. an interview with the Activities Director revealed she and her staff provide both monthly and daily scheduled activities to residents who want to participate as well as conduct 1:1 room visits with residents who wish to participate. She revealed she knew Resident #36, and he has had some decline lately and has not participated in activities. She could not remember how long he has not participated but did confirm he has not participated. She confirmed her activities assessments indicated the resident felt music, television, small group outings, religious activities and going outside for fresh air were important to him. She could not show documentation that he had been offered any of those types of activities within the past one month (11/2024) but was able to show 1:1 visits were completed. Her documentation could not identify what type of 1:1 activity was conducted, it just was documented 1:1 was completed. The Activities Director confirmed Resident #36 does refuse to do most of the activities offered but could not show documentation in the resident's record to support this. She also revealed his care plan with regards to Activities and participation needs to be updated to show his lack of activities interest. Further interview with the Activities Director revealed she could not support activities staff or direct care staff of offering him to go to any activities with regards to his assessed activities of interest. She could not support Resident #36 attending or offered any of the above listed calendar activities. On 11/21/2024 at 11:00 a.m. an interview was conducted with Staff D, CNA and Staff A, CNA. Both staff members revealed they knew Resident #36 and did not know if he likes certain group or 1:1 room activities. They both confirmed they have had him on their assignments in the past and do not remember if they had ever offered him to get up out from bed to go to any scheduled activities. They also confirmed they did not know what things he is interested in and also did not know if he likes to listen to music in his room or watch special television programs. They confirmed Resident #36 stays in his room and in his bed all day. On 11/21/2024 at 5:30 p.m. the Nursing Home Administrator revealed the facility did not have a specific policy and procedure related to resident activities. He revealed the facility will follow both State and Federal regulations as part of implementation of its activities program. The Nursing Home Administrator provided the Activities Director Job Description for review. The Job Description revealed the Activities Director reports to the Nursing Home Administrator. The overview of the Job Description revealed; The Director of Activities plans individual and group recreation services, both therapeutic and general, supervises recreation assistants and volunteers. The Director of Activities will also be responsible for developing, implementing, and supervising a full scope of recreation services in the nursing home to stimulate customers to have fuller and richer lives. Some of the Responsibilities the Activities Director holds, included but not limited to: (c) Responsible for developing, implementing & supervising all recreational services. (d) Responsible for all necessary documentation.

Based on record review and interview, the facility did not ensure medications were administered in a timely manner for two (#815, #763) of forty eight residents and failed to ensure wounds were monitored for signs and symptoms of infections and deterioration, and treatment orders were obtained and implemented for one (#64) of two residents sampled for pressure wounds, surgical incisions, and other skin conditions. Findings Included: 1.Review of the Admission Record for Resident #815 revealed she was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Heart Failure, Non-St Elevation Myocardial Infarction, Paroxysmal Afibrillation and Pulmonary Hypertension. Review of November 2024 Physician orders for Resident #815 revealed an order dated 11/4/24 for : Enoxaparin Sodium Injection Solution Prefilled Syringe 80 Mg/0.8 ML.(Enoxaparin Sodium) Inject 0.7 ml subcutaneously two times a day for Deep Vein Thrombosis (DVT) prophylaxis for 60 days. Review of the November Medication Administration Record ( MAR) for this medication indicated it was scheduled to be given at 9:00 a.m. and 9:00 p.m. An interview was conducted with Resident #815 on 11/18/24 at 12: 46 p.m. Resident #815 stated she received Lovenox (Brand name of Enoxaparin Sodium ) twice a day every 12 hours and she usually received the morning dose at 8:00 a.m. every day. She stated the nurse Staff S, Registered Nurse (RN) told her the medication was not in the medication cart and the nurse could not find it. Resident #815 stated she did not receive the 11/18/24 9:00 a.m. dose of this medication until 11:15 a.m. Resident #815 was concerned that the late administration of the medication would cause a problem with the next dose of the medication scheduled for 9:00 p.m. A review of a Medication Administration Audit Report for 11/18/24 showed the 9:00 a.m. dose of Enoxaparin Sodium Injection Solution Prefilled Syringe 80 Mg/0.8 ML.(Enoxaparin Sodium) Inject 0.7 ml subcutaneously two times a day for Deep Vein Thrombosis (DVT) prophylaxis for 60 days was administered at 11:15 a.m. on 11/18/24 and the 9:00 p.m. dose was administered at 8: 43 p.m. An interview with the Director of Nursing (DON) was conducted on 11/20/24 at 4: 03 p.m. The DON stated it was Staff S RN's first day on the cart by herself. The DON stated she did not see any communication in Resident # 815's record to the physician regarding the medication being administered late. An interview was conducted with Staff B, Unit Manager Station 1 on 11/20/24 at 4:25 p.m. Staff B stated Staff S did tell her the medication was not in the medication cart. Staff B stated she went and checked the Emergency Drug Kit ( EDK) for the medication however the correct dose was not stocked in the EDK She then called the pharmacy and found out the medication was delivered to the facility on [DATE]. Staff B stated she then went and checked the medication cart herself and found the medication in the cart which was then administered to Resident #815 by Staff S. Staff B stated neither she nor Staff S documented the late administration of the medication in the resident's record on 11/18/24 . She stated she notified the Nurse Practitioner but did not document the notification in the the resident's record. Staff B provided documentation on her phone of the text message that was sent to the Nurse Practitioner on 11/18/24. On 11/20/24, a late entry was recorded in Resident # 18's medical record of the notification to the Nurse Practitioner on 11/18/24. Further interview with the DON and Staff B revealed that the late administration of the 9:00 a.m. dose of Enoxaparin Sodium was not passed on to the 3:00 p.m. to 11:00 pm. nurse who would be administering the 9:00 p.m. dose. Review of a facility policy entitled : Standards and Guidelines : Medication Administration with a revision date of 01/24 revealed : Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescribe's orders, including any required time frame. 6. Medications are administered within one (1) hour before or after their prescribed time , unless otherwise specified ( for example, before and after meal orders, at bedtime). 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering shall document the rationale in the resident's medical record and notify the physician and responsible party if indicated. 50732 2. Review of the Admission Record for Resident #763 showed the resident was admitted to the facility on [DATE] and discharged on [DATE]. The admitting diagnoses included type 2 diabetes. Review of the Minimum Data Assessment (MDS) dated [DATE] showed Resident #763 had a Brief Interview for Mental Status (BIMS) score of 7 showing the resident had severe cognitive impairment. Review of Resident #763's Care Plan dated 06/03/2024 showed the resident was at risk for adverse effects of hyper/hypo-glycemia related to a diagnosis of diabetes and insulin use. Monitor blood glucose as ordered - notify physician or nurse practitioner if result exceeds parameters and obtain new orders if applicable. Observe as needed any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Review of Resident #763's Medication Discharge Report dated 05/31/2024 and given to the facility from the hospital upon the resident's admission to the facility showed the resident was prescribed insulin isophane-insulin regular (70/30 subcutaneous suspension) 40 units subcutaneous once a day as needed for hypoglycemia in the morning. Review of the Order Summary Report dated 05/31/2024 for Resident #763 showed the resident's physician in the facility ordered 70/30 suspension (insulin isophane and regular) inject 40 units subcutaneously one time a day for diabetes. Review of Resident #763's Medication Administration Record dated 06/01/2024 through 06/30/24 showed the resident was scheduled to receive 70/30 suspension (insulin isophane and regular) 40 units to be injected subcutaneously at 9:00 AM daily. Review of the Medication Audit Report dated 06/01/2024 through 06/24/2024 for Resident #763's insulin administration showed the resident was given insulin late 20 out of 24 instances as follows: Date Time Scheduled Time Administered 06/01/2024 06/01/2024 09:00 AM 06/01/2024 10:55 AM 06/02/2024 06/02/2024 09:00 AM 06/02/2024 10:47 AM 06/03/2024 06/03/2024 09:00 AM 06/03/2024 09:58 AM 06/04/2024 06/04/2024 09:00 AM 06/04/2024 10:57 AM 06/05/2024 06/05/2025 09:00 AM 06/05/2024 11:31 AM 06/06/2024 06/06/2024 09:00 AM 06/06/2024 11:11 AM 06/07/2024 06/07/2024 09:00 AM 06/07/2024 13:05 AM 06/08/2024 06/08/2024 09:00 AM 06/08/2024 11:07 AM 06/09/2024 06/09/2024 09:00 AM 06/09/2024 10:41 AM 06/10/2024 06/10/2024 09:00 AM 06/10/2024 09:19 AM 06/11/2024 06/11/2024 09:00 AM 06/11/2024 13:44 AM 06/12/2024 06/12/2024 09:00 AM 06/12/2024 09:58 AM 06/13/2024 06/13/2024 09:00 AM 06/13/2024 11:09 AM 06/14/2024 06/14/2024 09:00 AM 06/14/2024 10:35 AM 06/15/2024 06/15/2024 09:00 AM 06/15/2024 10:27 AM 06/16/2024 06/16/2024 09:00 AM 06/16/2024 09:24 AM 06/17/2024 06/17/2024 09:00 AM 06/17/2024 10:37 AM 06/18/2024 06/18/2024 09:00 AM 06/18/2024 12:13 AM 06/19/2024 06/19/2024 09:00 AM 06/19/2024 12:20 AM 06/20/2024 06/20/2024 09:00 AM 06/20/2024 10:43 AM 06/21/2024 06/21/2024 09:00 AM 06/21/2024 11:43 AM 06/22/2024 06/22/2024 09:00 AM 06/22/2024 11:33 AM 06/23/2024 06/23/2024 09:00 AM 06/23/2024 14:06 AM 06/24/2024 06/24/2024 09:00 AM 06/24/2024 11:09 AM An interview was conducted on 11/20/2024 at 2:45 PM with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff B said she was unaware Resident #763 had received late medications. An interview was conducted on 11/21/2024 at 2:00 PM with the Director of Nursing (DON). The DON said she did not remember any specifics regarding Resident #763. When presented with the Medication Audit Report dated 06/01/2024 through 06/24/2024 for Resident #763's insulin administration she reviewed the report and agreed the insulin was given to the resident late. The DON said she did not know why the medications were given late and she would have to investigate and return with the results. As of the exit conference on 11/21/2024, the DON did not return with results of her investigation. An interview was conducted on 11/21/2024 at 3:20 PM with the Nursing Home Administrator (NHA). The NHA said he was not aware of any issues regarding Resident #763 and the resident's stay at the facility. 37999 3. Review of Resident #64's admission record showed the resident was admitted on [DATE] with diagnoses not limited to nondisplaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, type 2 diabetes mellitus with hyperglycemia, and generalized muscle weakness. Review of Resident #64's Admission/Readmission Nursing Evaluation, effective 8/9/24, showed the resident was admitted from an acute care facility, alert and oriented to person, used a urinary catheter, and had the following skin conditions: - Right antecubital - Coccyx - redness open area - Right trochanter (hip) - Left heel - blister The Braden Scale completed with the admission evaluation showed the resident was rarely moist, bedfast, slightly limited, had adequate nutrition, and friction and shearing was a potential problem. The nursing evaluation showed the resident was at risk for skin breakdown and initiated the interventions of Treatments as ordered, Medications as ordered, Promote use of specialty mattress, cushions, and/or wedges as appropriate, and Monitor for pain and medicate as per orders prior to treatment/turning etc. to enhance comfort. Review of Resident #64's post-admission Skin/Wound note, dated 8/10/24 at 12:51 p.m. showed Resident #64 had a deep tissue injury (DTI) to the left heel, measuring 2.5 x 2.5 centimeters (cm) and a right hip incision from surgery with glue and steri-strips in place. The note indicated there was an old wound to coccyx which was not open and healed. Review of Resident #64's Weekly Skin Check, dated 8/12/24 showed redness to the left toe(s) and redness to the buttock area, no open area noticed. Review of Resident #64's Weekly Skin Check, dated 8/14/24 at 10:00 p.m. revealed Existing blister on the left heel, discoloration on the right heel and back of foot, discoloration groin areas. Barrier cream applied to groin and buttocks to prevent skin breakdown. Review of Resident #64's progress note dated 8/16/24 at 10:58 p.m. showed a Braden scale had been completed with the resident scoring a 15 (of 23) revealing the resident was a low risk for skin impairment. Review of Resident #64's Weekly Skin Check dated 8/21/24 at 10:59 p.m. showed the resident had no new skin issues. Review of Resident #64's progress notes from 8/15/24 to 8/23/24 did not show staff were monitoring or had notified the physician or representative of the existing blister on the left heel or the discoloration on the right heel and back of foot as described in the Weekly skin check dated 8/14/24. The notes did not reveal staff were monitoring the resident's right hip surgical incision for signs or symptoms of infection. Review of Resident #64's progress note, dated 8/23/24 at 10:00 p.m. showed a Braden Scale had been completed and the resident scored 14 (of 23) showing a moderate risk form skin impairment. Review of Resident #64's Weekly Skin check, dated 8/24/24 at 8:49 p.m. revealed the resident had an open blister to both right and left heels. The comments reported open blister under bilateral heels. The progress notes did not show any notes by nursing staff as to the description of the wound bed or peri-wound area of the bilateral open blisters. The note did not show the resident representative, or physician was notified of the open areas. The Weekly skin check also did not report on the surgical incision the resident had been admitted with. Review of Resident #64's progress notes did not show staff were monitoring the open blisters between 8/24 and 8/28/24. Review of Resident #64's progress notes showed on 8/28/24 at 9:44 a.m., Resident was initially evaluated by the wound Dr. this morning due to recent eschar noticed on both heels. After the evaluation the doctor ordered to continue to apply betadine on both heels and leave open to air. Resident heels were left offloaded. The resident was educated about the treatment and understand. Review of Resident #64's Wound Evaluation, dated 8/28/24 at 9:36 a.m. showed an In-house Acquired Left heel unstageable pressure ulcer measuring 3.1 x 2.8 x 0 cm. The documentation showed the wound had been identified on 8/23/24 with no exudate, 100% black eschar, defined wound margins, and a treatment of betadine daily and as needed leaving the area open to air (OTA). The note revealed the resident was notified on 8/28/24 at 7:00 a.m. Review of Resident #64's Wound Evaluation, dated 8/28/24 at 9:19 a.m. showed the resident had an In-House Acquired Right heel unstageable pressure ulcer measuring 4.5 x 4.2 x 0 centimeters (cm). The documentation showed the wound had been identified on 8/23/24 with no exudate, 100% black eschar, defined wound margins, and a treatment was obtained on 8/28/24 for betadine daily and as needed leaving the area OTA. The note revealed the resident was notified on 8/28/24 at 00:00 (12:00 a.m.). Review of Resident #64's August 2024 Medication Administration Record (MAR) did not reveal staff were monitoring the resident's surgical incision, discoloration to right heel or the progression to an open blister , or had monitored the existing blister on the left heel. Review of Resident #64's August 2024 Treatment Administration Record (TAR) revealed staff were not monitoring the resident's surgical incision for signs/symptoms of infection, or for changes in the resident's left heel existing blister as reported on the day of admission. The TAR showed wound care orders had been obtained on 8/27/24 for the application of Betadine on the Right/Left heel and instructed to leave open to air every day shift for eschar. Review of Resident #64's care plan revealed the following: - At risk for skin impairment related to (r/t) anemia, diabetes, fragile skin, (and) weakness/decreased mobility, Pressure area to left heel, right heel (and) redness to coccyx. The focus was initiated on 8/10/24. The interventions included but no limited to Monitor/observe skin while providing routine care. Notify the nurse for any area of concern as indicated, initiated 8/10/24. - At risk for adverse effects for hyper/hypo-glycemia r/t diagnosis of diabetes (and) insulin use, initiated 8/12/24. The interventions included but not limited to Monitor feet for open areas, sores, pressure areas, blisters, edema, or redness. Report to MD indicated, initiated 8/12/24. An interview was conducted with Staff R, Registered Nurse/Wound Care (RN/WCN), on 11/21/24 at 10:15 a.m. Staff R reported she would have expected to be notified of skin issues on Resident #64's right heel prior to the development of eschar. Staff R reported dressing the resident's wounds daily Monday through Friday and floor nurses were responsible for wound care on the weekends. An interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 11/21/24 at 1:34 p.m. The DON stated the resident had come in with one pressure area and had developed one while at the facility and mobile. The facility was going to work up the wounds to see if they were vascular. The DON stated eschar could show up and could deteriorate rapidly. Review of the policy - Prevention of Skin Impairments/Pressure Injury, revised 1/2024, revealed The purpose of this policy is to provide information regarding identification of skin wound risk factors and interventions for specific risk factors. The guideline instructed to Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The risk assessment included: - 1. Assess the resident on admission for existing wound risk factors. - 2. Conduct a comprehensive skin assessment upon a mission, including: - a. Skin integrity- any evidence of existing or developing pressure ulcers or injuries; - b. Areas of impaired circulation due to pressure from positioning or medical devices. - 3. Inspect the skin when performing or assisting with personal care or activities of daily living (ADLs). - a. Identify any signs of developing skin wound (i.e. Non blanchable erythema/rashes). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; - b. Inspect pressure points (sacrum, heels, products, toxics, elbows, ischium, trochanter, etc.). - c. Wash the skin after episodes of incontinence. - d. Reposition resident as indicated on the care plan. The preventions based on the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to: a. Redistribute pressure (such as repositioning, protecting and/ or offloading heels, etcetera (etc.)); b. Minimize exposure to moisture and keep skin clean, especially a fecal contamination; c. provide appropriate, pressure redistributing, support surface; d. provide non irritating surfaces; and e. maintain or improve nutrition and hydration status, when feasible. Adverse drug reactions related to the residence drug regimen may worsen risk factors for development of, or for non healing pressure ulcers (PU)/ Pressure injuries (PI)s (For example, by causing lethargy or anorexia or creating/ increasing confusion) and should be identified and addressed. These interventions should be incorporated into the plan of care and revised as the condition of the resident indicates. The policy instructed for the Monitoring/Documenting as follows: 1. Evaluate, report, and document potential changes in the skin. 2. Notify the physician and the resident/ resident representative of changes in the skin. 3. Review the interventions and strategies for effectiveness on an ongoing basis. 4. Evaluate open areas (pressure/ surgical areas) per physician orders.

Based on observation, record review and interview the facility failed to ensure a hazarded free room environment, with (brand name) Air Freshener Spray found in one resident room, Resident (#99) out of eight residents sampled. Findings include: During an observation on 11/18/2024 at 10:00 a.m., and 12:41p.m., Resident #99's room was observed with the door open, where other residents were able to enter the room. Her dresser was observed with two air freshener sprays. The bathroom was observed with one additional air freshener spray on the bathroom rail over the toilet. During an interview on 11/19/2024 at 10:00 a.m., with Resident #99. She stated the staff took away her air fresheners today. She stated she has had her sprays on her dresser for about a month but was told by staff today they had to take it away because she is not allowed to have air freshener sprays in her room. Review of an Admission Record dated 11/21/2024 showed Resident #99 was admitted to the facility originally on 6/4/2024 and readmitted on [DATE] with diagnoses to include but not limited to Dysarthria Following Cerebral Infractions, Type 2 Diabetes Mellitus Without Complications, Unspecified Asthma, Uncomplicated. Review of Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. During an interview conducted on 11/21/2024 at 2:00 p.m., with the Nursing Home Administrator, (NHA), the NHA stated when a resident is admitted to the facility, they conduct a 24-hour meeting to discuss the facility's guidelines with the resident. They also conduct a follow-up discussion during the care plan meeting in which they go over the facility do's and don'ts. If a resident has air freshener in the room, they find out if the resident is alert. If the resident is alert the facility would provide the resident with a lock, and they are allowed to have items locked up in their rooms. If they can't use the lock, they would have the discussion with the resident's family to tell them not to bring in air freshener. During an interview conducted on 11/21/2024 at 2:30 p.m., with the Director of Nurses (DON) the DON stated she was not aware that Resident #99 had air freshener spray in her room. She stated the resident orders a lot of items that are delivered to the facility. She stated that Aerosol sprays are not allowed in the facility, so staff should have taken the spray out of the resident room and educated her about the facility process. She stated she will have to do further training with her staff and residents about the use of Aerosol spray. (Photographic Evidence obtained) The facility did not have a policy to provide related to the prohibited use of Aerosol Sprays.

Based on observation, record review and interview, the facility failed to ensure medications were administered at the correct dose for one (Resident #90) out of 26 residents sampled. Findings Included: During an observation on 11/18/2024 at 9:49 a.m. Resident #90 was observed in bed, she was not able to answer questions regarding her care. Review of Resident #90's admission record revealed resident #90 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and depression. Review of Resident 90's admission Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) of 04 out of 15 showing severe cognitive impairment. Review of Section N. Medications revealed Antipsychotic and antidepressant. Review of Resident #90's orders revealed on 11/07/2024 an order for Seroquel Oral Tablet 25 milligrams (MG) (Quetiapine Fumarate) Give 3 tablet by mouth in the evening for agitation and an order for Seroquel Oral Tablet 25 MG Give 25 MG by mouth two times a day for Anxiety. Review of Resident #90's Medication Administration Record (MAR) revealed the following: Seroquel Oral Tablet 25 MG one tablet was given on 11/07/2024 at 5:00 p.m. Seroquel Oral Tablet 25 MG one tablet was given daily 11/08/2024 to 11/20/2024 at 9:00 a.m. and 5:00 p.m. Seroquel Oral Tablet, three 25 MG tablets were given daily 11/07/2024 to 11/20/2024 at 8:00 p.m. Review of Resident #90's Behavior Monitoring revealed on 11/07/2024 0 No Behaviors; 11/08/2024 NA (Not Applicable); 11/09/2024 to 11/14/2024 0 No Behaviors;11/15/2024 NA ;11/16/2024 to 11/20/2024 0 No Behaviors. During an interview on 11/21/2024 at 2:00 p.m., with the Director of Nursing (DON), she stated she called psych about the Seroquel order and psych told her they did not write the order for Seroquel at bedtime and must have been ordered by the attending physician. She stated she would need to reach out to the attending physician for clarification. During a phone interview on 11/21/2024 at 3:13 p.m., the Attending Physician, stated that he remembered Resident #90 and did remember ordering Seroquel 25 MG 3 tabs at bedtime for agitation on 11/07/2024 and he was aware that she was also taking Seroquel 25 mg twice daily. He stated the 75 mg dose was only meant for a short period of time and not an ongoing order. He stated this was not a correct intervention. He stated, It probably should have been ordered for her to have 25 MG dose in the morning and then the 75 MG at bedtime. He stated no one from the facility had called him to clarify the order and that he would bring this up in their next Quality Assurance meeting. On 11/21/2024 at 4:45 p.m., the facility was asked to provide a policy for Unnecessary Medication and provided a policy for Gradual Dose Reduction.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-four medication administration opportunities were observed, and three errors were identified for two (#13 and #11) of four residents observed. These errors constituted an 8.82% medication error rate. Findings included: 1. On 11/19/24 at 8:43 a.m., an observation of medication administration with Staff P, Registered Nurse (RN) was conducted with Resident #13. The staff member dispensed the following medications: - Gabapentin 800 milligram (mg) tablet - Zoloft 100 mg tablet - Megestrol AC Suspension 40 mg/milliliter (mL) - 10 mL - Artificial Tears lubricant eye drops (contained glycerin, hypromellose, and poly glycol) -Buspirone (Buspar) 5 mg tablet Staff P confirmed dispensing 3 oral tablets prior to entering Resident #13's room. The resident refused the liquid Megace reporting refusing all along. The staff member obtained a blood pressure of 98/64, administered oral medications, then placed one drop of Artificial Tears in each eye. The staff member left the room and took the Megace to the unit's medication room and disposed of it in a jug of medication disposer. Staff P dispensed the resident's as needed medication, Oxycodone 5 mg tablet, called the attending physician for instructions regarding the resident's bathyspheres medication, then administered the pain medication. Review of Resident #13's November Medication Administration Record (MAR) revealed the following: - Staff P documented that the 9:00 a.m. scheduled dose of Megace had been administered. - Artificial Tears Ophthalmic Solution 1% (Carboxymethylcellulose Sodium) - Instill 1 drop in left eye four times a day for dry eye. The eye drops were administered in both eyes and the ingredients of the administered drops did not contain Carboxymethylcellulose Sodium. 2. On 11/21/24 at 7:48 a.m. an observation of medication administration with Staff Q, Licensed Practical Nurse (LPN) was conducted with Resident #11. The staff member searched the medication cart reporting having to go to the refrigerator for the resident's Lispro insulin and also had to get the laxative. The staff member went to the medication preparation room and did not obtain the resident's Lispro but did obtain the resident's Humalog 70/30. The staff member dispensed the following medications: - ClearLax polyethylene - in a 5-ounce cup of water - Pantoprazole 40 mg tablet - Tamsulosin 0.4 mg tablet - Lexapro 10 mg tablet - Carvedilol 6.25 mg tablet - Allopurinol 100 mg tablet The staff member confirmed dispensing 5 tablets and the laxative. Staff Q obtained a blood glucose level of 276 from the resident, administered the oral medications followed by the assisting resident with drinking the laxative. Staff Q returned to cart. The resident dialed the resident's Humulin 70/30 pen to 12 units, primed to approximately 6 units then dialed back to 10 units, returning to the resident to inject into the left abdomen at 8:16 a.m. On 11/21/24 at 8:18 a.m., a staff member served Resident #11 the morning meal and the resident was observed feeding himself while sitting in a wheelchair. Staff Q walked to the electronic medication dispenser on the other unit and was unable to obtain the resident's Lispro, stated thinking the facility had a refrigerator kit and would have to check with the unit manager. The staff member searched the refrigerator kit on the unit and was unable to locate the necessary insulin. Staff Q informed Staff O, LPN/Unit Manager of needing to talk to her after Staff O finished assisting a resident with eating. Staff Q notified the Unit Manager at 8:30 a.m. of the situation regarding the insulin. On 11/21/24 at 8:45 a.m., Staff O arrived on the unit and stated the Lispro was in the other kit. Staff O confirmed the insulin was late, I understand. On 11/21/24 at 8:47 a.m. Staff Q reported going to clear off the red and Resident #11 was going to get 6 units of insulin per sliding scale, the staff member primed the insulin Lispro pen, dialed the dosage selector to 6 units and injected into the residents right lower quadrant at 8:51 a.m. Review of Resident #11's Medication Administration Record revealed the Insulin Lispro 100 unit/milliliter solution pen-injector was to be injected per sliding scale subcutaneously with meals for diabetes mellitus at 7:05 a.m. The observation showed Resident #11's insulin Lispro was not available to Staff Q and the medication was administered approximately 30 minutes after the resident had eaten and 1 hour 46 minutes after it was scheduled to be administered. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 2:03 p.m. The DON was made aware of the observed errors. She stated the procedure (regarding Resident #11) was to notify the physician and the family if the medication was not available. The discussion revealed the medication was available in the other refrigerator and was given late after the resident had eaten breakfast. Review of the policy - Medication Administration, revised 1/2024 revealed medications are ordered in administered safely and as prescribed. - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime).

Based on observation, record review and interview, the facility failed to coordinate dental services for one resident (#18) out of eight residents sampled. Findings include: During an observation on 11/18/24 at 2:05 p.m., Resident #18 was observed sitting up on her bed, fully dressed with no signs of distress. She stated her only concerns were that she had missing teeth, and she really wanted to have a set of dentures so she could chew her food. She stated she did not know what happened to her dentures. During an observation on 11/20/2024 at 11:45 am., Resident #18 was observed sitting up in her wheelchair eating her lunch. She said she was not able to eat her green beans because she did not have any teeth. She stated the facility had not assisted her with dental services. On 11/20/2024 at 2:20 p.m., an interview was conducted with Staff M, Certified Nursing Assistant (CNA). Staff M stated every morning she provided oral care to all her residents. For residents who wore dentures she provided them with denture care. She stated she put Resident #18 dentures in her mouth this morning, so she did not know why Resident #18 did not have her dentures. During the interview with Staff M, Resident #18 interrupted and stated she had not had her dentures in a while, and she really needed them because she was having trouble eating her food. Staff M than stated she did not normally work on the side with Resident #18, and she thought she had put Resident #18 dentures in her mouth. Review of an Admission Record date 11/21/2024 showed Resident #18 was admitted to the facility with diagnoses to include but not limited to Chronic Atrial Fibrillation, unspecified, Type 2 Diabetes Mellitus Without Complications, Need for Assistance with Personal Care. Review of a Quarterly Minimum Data Set, (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of a Social Service assessment dated [DATE] showed Resident #18 was marked no to indicate she did not have dentures. Review of a [name of dental service] patient note dated 8/30/2024 showed Resident #18 was seen for a Comprehensive Exam and had an impression for upper lower dentures Resident #18 had a care plan for oral/dental health problems related to Alzheimer's Disease, Depression, Diabetes Mellitus (DM), Functional Impairment limiting ability to perform oral hygiene; wears dentures, prefers to remove them at times, date initiated 6/26/2024, revision date 11/21/2024. The care plan goal was for Resident #18 to be free of infection, pain or bleeding in the oral cavity by through review date. Date initiated 6/26/2021, revision on 7/24/2023, Target date 12/18/2024. The care plan interventions include Coordinate arrangement for dental care, transportation as needed/as ordered, ensure dentures are worn, date initiated 6/26/2021, revision on 6/26/2021. During an interview on 11/21/2024 at 2:00 p.m., with Staff F, Care plan Coordinator, she stated when a resident was admitted to the facility, nursing, speech and social services did the resident screening to see if the resident had natural teeth or upper or lower partials. As they build the comprehensive care plan, she gathered the information from the assessments, then she care planned the resident's dental status. Resident #18 had a Quarterly last done on 9/18/2024 and it showed the resident did not have broken or loosely fitting dentures. She stated upon review of the social services and dietary assessment, Resident #18 was marked not to have dentures. Which was not accurate because Resident#18 had a care plan showing she had dental problems and she wore dentures. She stated she updated Resident #18's care plan today, 11/21/2024, to reflect the resident did not have her dentures. She stated staff should have told her as soon as the resident lost her dentures, and she should have been notified when resident had impressions taken and was waiting for her dentures, so a note could have been out in the system. During an interview on 11/21/2024 at 2:30 p.m., with the Social Service Director (SSD). She said the resident had dentures but she lost them because she liked to wrap them up in paper napkins and put them in her purse. She stated the resident was last seen on 8/30/2024 by [name of dental service] and they noted they took impressions for upper and lower dentures. She stated she did not follow up with the dentist about the resident's impressions because she was not aware that Resident #18 had impressions taken. She stated when she went to Resident # 18 room, to look for the resident dentures, she was able to confirm that the resident did not have her dentures. During an interview on 11/21/2024 at 3:00 p.m., with the Director of Nurses, DON. She stated if the CNA(s) notice that their residents had issues with their dentures, such as lost or broken, then the aide should report the issues to their nurse. The nurse would report the issue to the nursing supervisor, who would get the resident added to the dental list. If it was a resident that had issues with their dentures, such as broken or lost, then the nurse would assess the resident to make sure there were no issues with the resident having difficulty in swallowing, chewing, or a decrease in oral intake. She stated Resident #18's aides should have reported the resident's missing dentures to their nurse, so they could have assessed the resident to make sure she had no issues until her dentures came in. Review of the facility policy tilted; Dental Consults Revised dated 1/2024 showed Standard: The facility will facilitate dental services through the service of a Consultant Dentist as indicated. Guidelines: 1. Our facility does not have dental providers on staff, and therefore contracts with external providers to provide dental services to residents as indicated. 2. The facility will contract with an external Dental provider to provide Dental Services to residents as indicated and provide the following: 1. Providing consultation to physicians and providing other services relative to dental matters.

Based on resident meal observation and staff interview, it was determined the facility did not ensure one (Resident #816) of three residents observed during a lunch meal received food presented in an attractive and appealing manner. Findings included: Review of the record for Resident # 816 revealed diagnoses which included Unspecified Alzheimer's disease, Unspecified Dementia, Unspecified Protein-Calorie Malnutrition and Dysphagia Oropharyngeal Phase. Review of the record for Resident # 816 indicated a diet order for Pureed Texture Thin Consistency (Photographic Evidence obtained). An observation of the lunch meal for Resident # 816 was conducted on 11/18/24 at 12:11 p.m. Resident # 816 was observed in her bed and the lunch meal was placed on the overbed table by a CNA (Certified Nursing Assistant) who was observed to remove the lid on the entree and then exit the room. A dinner size plate was located on the tray and was observed to be filled with a soupy consistency of pureed foods running together on the plate (photographic evidence obtained). An interview was conducted with the Dietary Manager on 11/20/24 at 2:15 p.m. She reviewed the photograph of the lunch meal served to Resident # 816 on 11/18/24. The Dietary Manager stated the presentation was not acceptable and said, that was gross. She stated she did not know how the meal got out of the kitchen looking like that.

Based on observation, record review, and interview, the facility failed to implement an effective infection control program related to 1. the use of Personal Protective Equipment (PPE) for one (#88) of one sampled resident for transmission-based precautions, 2. failed to ensure fingernails of staff were kept in a manner that prohibited the growth of microorganisms and allowed for sufficient hand hygiene, and 3. failed to ensure the storage of personal hygiene equipment for one resident (#91) out of ten sampled residents related to oral hygiene. Findings included: 1. On 11/18/24 at 9:14 a.m. an observation was made of a Contact precaution sign posted outside of Resident #88's room. The sign showed STOP - CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The hallway outside or near the resident's room did not show any PPE was available for staff and/or visitors to don prior to entering the room. During the observation on 11/18/24 at 9:14 a.m., Staff K, Social Work Assistant (SWA) entered the room and stood at the bed of Resident #88's bed without donning any PPE, then Staff J, Licensed Practical Nurse (LPN) entered the room and spoke with the resident. Both staff members left the room and Staff J stated she thought the resident was off precautions since the (PPE) caddy was gone. The staff member read the Contact precaution sign and stated if the sign was still posted staff should dress in PPE. The staff members confirmed the PPE containers were 3-drawer storage unties that were placed in the hallways. Shortly after the observation and interview with Staff K and Staff J, the Infection Preventionist (IP) was seen on B-hall (on other side of the nursing station from Resident #88's room). The IP stated staff got PPE from the shower room and began to walk around the nursing station, stopping at Resident #88's room with the Contact precaution sign posted and stated staff only had to wear PPE when they were providing direct care for the resident. The IP stated staff had to dress in PPE for Resident #88 prior to entering the room. This writer and the IP walked to the shower room at the opposite end of the hall and around the corner. The IP stated PPE was kept in a caddy outside the room for contact precautions and inside the room for Enhanced Barrier Precautions (EBP). The IP stated the PPE kept in the shower room was for restocking the caddies. The IP confirmed there was no PPE available outside of the resident's room. Review of Resident #88's Admission Record showed the resident was admitted to the facility with diagnoses included but not limited to type 2 diabetes mellitus without complications, generalized muscle weakness, and need for assistance with personal care. Review of Resident #88's Order Summary Report showed an order for Contact Precautions: Encourage and assist resident to maintain contact precautions for urinary tract infections (UTI) e.coli every shift for UTI e.coli for 7 days, start date 11/11/24 and end date 11/18/24. Photographic evidence was obtained on 11/18/24 at 9:20 a.m. Review of policy - Transmission Based Precautions, revised 2/2024, showed All staff receive training on transmission-based precautions upon hire and at least annually. The procedure for Contact Precautions revealed: a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens. 2. On 11/18/24 at 11:05 a.m., Staff L, Certified Nursing Assistant (CNA) was observed outside of room [ROOM NUMBER]. The staff member reported looking for someone to assist getting a resident up. The observation revealed Staff L's had unnatural fingernails, painted a blush pink color with white tips and a variegated yellow/pink nail on one observed hand. The nails extended a minimal of approximately 1/2 past the tip of the fingertip. Staff L confirmed the fingernails were fake. 3. On 11/20/24 at 2:23 p.m., Staff M, CNA, was observed documenting at a wall-mounted kiosk. The staff members nails were square-cut, painted a pink iridescent color extending approximately 1/4 past the tip of the fingers. 4. On 11/20/24 at 2:24 p.m., Staff N, Licensed Practical Nurse (LPN) was observed with square tip nails with tips painted a light grass green color extending approximately 1/2 past the fingertips. The staff member was observed assisting an unknown resident in the hallway, pulling the resident's wheelchair towards a room. 5. On 11/21/24 at 5:09 p.m. the Director of Nursing (DON) was observed with nails colored a pinkish-nude color with the ends extending slightly past the ends of fingertips. The DON reviewed the statement obtained from the facility regarding staff hygiene acknowledging it came from the staff handbook. She stated fingernails (length) should not interfere with care. The DON read further and acknowledged the handbook reported fingernail length no longer than 1/4 or fingertip length. She stated it would probably encompass all of us and stated also no artificial nails. The staff handbook, section 5-17 - Employee Dress and Personal Appearance revealed Employees are expected to report to work well-groomed, clean, and dressed according to the requirements of their position. Fingernails should be clean and well-manicured. Fingernails length should not interfere with customer care, job performance, or infection control guidelines (1/4 or fingertip length). Nail polish, if worn, should not be chipped. Review of the Centers of Disease Control and Prevention (CDC) guidelines for Clinical Safety: Hand Hygiene for Healthcare Workers, February 27, 2024, (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) revealed: - Natural nails should not extend past the fingertip. - Do not where artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive care units or operating rooms. Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and hand washing. - Some studies have shown that skin underneath rings contain more germs than fingers without rings. -Further studies should determine if wearing rings increases the spread of deadly germs. 6. On 11/18/24 at 11:31 a.m., an observation was made of Resident #91's bathroom. The observation showed two toothbrushes lying uncovered behind the sink's faucet with multiple tubes of toothpaste, including one opened tube. On 11/21/24 at 9:01 a.m., Resident #91's bathroom was observed with multiple tubes of toothpaste and two toothbrushes laid behind the sink's faucet. Resident #91 reported wearing dentures and staff did not clean them but did put them in. On 11/21/24 at approximately 9:30 a.m., the oral hygiene items in the bathroom of Resident #91 was observed with Staff O, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff O stated toothbrushes should not be stored like that and that's gross. Review of Resident #91's Functional Abilities and Goals comprehensive assessment, dated 9/16/24, shows the resident required set up assistance with oral hygiene and supervision with transferring from bed to chair. Review of Resident #91's care plan showed the following: - That has potential or intellectual or health concerns. Has cognitive impairments and needs assistance to complete oral care task. Has obvious or suspected cavities or broken natural teeth which may lead to complications such as mouth sores, infection, or pain, dated initiated 7/16/24. The interventions instructed staff to Assist with or provide mouth care as needed to ensure task completion. Review activities of daily living (ADL) care plan interventions for degree of assistance needed. Review of the policy - Infection Control Infection Prevention and Control Program, revised 1/2024, reported An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Photographic evidence was obtained.

Based on record review and interviews, the facility failed to ensure a resident's representative was informed timely of a change in medication, a change in medical condition and a change in treatment orders for two residents (#4 and #1) out of six sampled residents. Findings included: 1. A review of Resident #4's clinical chart revealed an admitted ,d+[DATE]. The clinical record revealed the resident was transferred to the hospital on 03/28/2023. The diagnosis list included: unspecified dementia, atherosclerotic heart disease of native coronary artery without angina pectoris; Type 2 Diabetes Mellitus with unspecified complications; hypertension; gastro esophageal reflux disease without esophagitis; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #4's progress notes revealed the following: 02/11/2023, 14:18 (2:18 p.m.): Late entry, discolored areas noted right heel. Left foot bunion and outer pinky area and left inner ankle skin intact at all areas. Order for skin prep in place. (No documentation of physician notification or family notification.) 02/12/2023, 14:59 (2:59 p.m.): Started on skin prep bilateral feet. Podus boots in place. 02/12/2023, 15:30 (3:30 p.m.): Change in condition: Skin wound or ulcer. The physical assessment documented a skin evaluation, Discoloration; with a summary: skin check done discoloration noted. With the primary care provider feedback: Recommendation: skin prep 02/18/2023, 01:12 (1:12 a.m.): MD (Medical Doctor) notified of minimal swelling with light pink discoloration on the left foot along the side of the existing blister. No new orders given at this time. Will monitor area for any changes and notify physician. 02/18/2023, 03:52 (3:52 a.m.): New order from physician for Keflex 500 mg (milligrams) bid (two times a day) x 7 (seven) days for blister/ skin infection on left foot. Family member notified; medication order placed with pharmacy. 02/21/2023, 11:48: Discontinue multipodus boots, r/t (related to) left foot blister. Resident continues with ABX (antibiotic) with no ill effect. MD in agreement, [family member] called and updated with new order. 03/15/2023, 14:08 (2:08 p.m.): A care plan meeting was attempted with the POA (power of attorney) but got no response. The care plan meeting was held amongst the team. There are no changes with care. Resident eat meals with the assist group. Resident may be discharged with spouse to a facility with memory care or locked unit. Resident will remain a full code. 03/19/2023, 11:04: Change in condition: Skin wound or ulcer. The nursing observations: During skin check nurse noted the open area, started treatment. DON notified. The Primary Care Provider feedback: Recommendations: Continue with present TX (treatment), until assessed by TX nurse and Wound Doctor. (No family notification documented.) 03/27/2023, 20:36 (8:36 p.m.): MD made aware of rapid declining wound to patient's left lateral foot. Family at bedside. Wound appears black in color and redness to exterior of the wound. No drainage or slough. Wound is dry. New order received for doppler, x-ray and labs due dx (diagnosis) of diabetes, and atherosclerosis. Family made aware of orders and treatment that is in place will continue as ordered by MD. 03/28/2023, 16:55 (4:55 p.m.): Change in condition: Skin wound or ulcer. Nursing observations, recommendations are: Send to ER (emergency room ) for eval (evaluation) d/t (due to) wound. Primary Care Provider Feedback: Recommendation: OK to send to ER for evaluation. New testing orders: Venous Doppler, X-Ray. 03/28/2023, 17:49 (5:49 p.m.): MD made aware of diagnostics new order made to send patient to ER for vascular calcification per X-Ray and rapid declining foot ulcer to rule out occlusion and osteomyelitis. Patient not responding to recent topical and abt treatment to the foot ulcer. Patient has history of dx, and x-rays also reveal osteoporosis. Family made aware patient discharged to (hospital). Report given to ER nurse. Patient is clean and dry at the time. [family member] states the patient's groin is red. This nurse as well as the floor nurse and paramedics observe perineal area is clean dry and free from redness, irritation, or breakdown at this time. A review of Resident #4's Treatment Administration Record (TAR) for 02/2023, revealed the following treatment orders: Apply skin prep to left inner ankle, bunion and left outer small toe q (every) shift for discolored areas, start date 02/12/2023. The treatment was documented to be provided as ordered. Apply skin prep to right heel every shift for discolored area, start date 02/12/2023. The treatment was documented to be provided as ordered. A phone interview was conducted with Resident #4's family member. He stated on 02/18/2023, he had gone to the facility, and they told him Resident #4 had a wound on his left foot, he had looked at it and it looked like it was healing. He stated, on 02/19/2023, they called me again and told him about the wound. On 02/20/2023, he had gone to the facility and observed Resident #4 with a boot on, and he had spoken to Staff I, Licensed Practical Nurse (LPN) who said she did not know why the boot was on, but she would recommend removing it. On 03/19/2023, he stated he was called, and they told him Resident #4 had a wound on his buttocks. On 03/27/2023, he stated he visited, and he was concerned because the resident was always covered, and always in bed. He stated the resident had no boots on his foot and when he lifted the left foot, he saw all the black on the resident's foot. He stated he was upset and talked to the nurse to find out how it happened. He stated he asked to see the supervisor and was told the blackened area happened yesterday. He stated he also discovered the resident had a wound on his right foot. He stated the supervisor said he would tell the wound nurse. On 04/20/2023 at 3:15 p.m., an interview was conducted with Staff F, Certified Nursing Assistant (CNA). She stated, I assisted a couple of times. I helped the other CNA. When I came in June, he did not have any skin conditions. One time, before he left, I helped with his care; he had something on his left foot. She stated approximately 60% of the side of his foot was black. She stated Resident #4 was a total care resident. She stated, Every day we would get him out of bed. He had a special chair. We used a Hoyer lift. Yes, he had contractures, his legs, and his arm. Yes, we would have to toilet him; change him. On 04/20/2023 at 3:40 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated for a change in skin or skin impairment, she would expect the CNAs to let the nurse know. She stated We have protocols. We can apply Zinc. They always let me know. I look. Anything stageable, we get a wound consult. If the impairment was not there yesterday and there today, they let us know. We have weekly skin checks. If something is new, we are supposed to notify the doctor, the family and do an assessment. Staff I stated for a wound consult, It is easy. We just put them on the list. She stated the reason for the wound consult is to see what treatment is best for that area. Staff I reviewed Resident #4's clinical chart and confirmed she was not able to find a wound consult visit documented in the clinical chart for 2023. On 04/20/2023 at 1:30 p.m., A review of Resident #4's progress note for 02/11/2023, 14:18 (2:18 p.m.) was conducted with the Director of Nursing (DON). She confirmed the clinical chart had no documentation of the resident's representative being notified about the skin impairment. She also confirmed the chart indicated the doctor was called on 02/12/2023 at 5:30 p.m., which was untimely. The DON indicated the family should be notified immediately. On 04/20/2023 at approximately 4:20 p.m., an interview was conducted with the DON. She stated, for the wound on Resident #4's left foot, It started off as black, scabs, it was a blister. When it started turning black, we ordered the ultrasound. She confirmed the clinical chart had no measurements of the wound. She confirmed on 03/27 and 03/28; the wound covered approximately 60 % of the outer area of the resident's foot. The DON stated, For the wound doctor, he does not see every Stage II wound. The DON confirmed she spoke with the family, and they were under the impression the wound was a pressure wound. She stated they recommended sending the resident out. She stated the resident was transferred to the hospital, and she could tell the family was upset. She stated they called the physician and gave the results. She stated they conducted in-services for family communication. She stated she did not document a grievance form, because she thought there would be something they could do. On 04/20/2023 at 5:05 p.m., the ADON (Assistant Director of Nursing) provided an in-service education record, titled Family & Resident Notification for change in condition, dated 03/29 & ongoing, program length: 15 (fifteen minutes). The Program brief description read: With any change in condition and new orders, family and patient must be notified. Ex (example) (new labs, abt [antibiotic], wounds, etc). Twenty-five nurses had signed the in-service sign in sheet. In addition, attached to the in-service documentation was an agenda for an All Staff Meeting, dated 04/14/2023, which was documented to be conducted by the DON. Verbiage in the agenda included: Notification of family members: make sure when there is a change in condition to notify MD, family and management. Sixty-eight staff had signed the attendance roster. A review of the facility's employee roster documented the facility had 37 Nurses and 59 Certified Nursing Assistants, for a total of ninety-six employees. A review of hospital records for Resident #4, dated 03/28/2023, documented a history of present Illness: This (geriatric) patient . Patient has hypertension and hyperlipidemia. The patient has chronic left and right foot wounds. Patient had bilateral lower extremity ultrasound that showed good flow. On evaluation the patient has a fifth digit infection on the left side with also (sic) and also on the medial aspect of the foot plus on the right side the second toe looks infected.The patient will be on Cefepime and Vancomycin. Further review of the hospital record, a Podiatry Consult, dated 03/29/2023: On examination of lower extremities, the patient has atrophic skin bilaterally with an oval grad 1-2 ulceration on the medial aspect of the 1st metatarsal head of the left foot with a dense eschar which upon removal show a small opening with the droplet of pyrogenic exudate but uncertain if he goes all the way to capsule certainly no bone exposure is seen. There is minimal erythema surrounding the ulcer site which measures about 1 cm in diameter and no other lesions are seen on the left foot. Again, the skin is atrophic, and the pedal pulses were barely palpable to nonpalpable due to nonpitting edema to the area no hair growth patterns of bilateral lower extremities. There is a small excoriation on the lateral fifth metatarsal head on the right foot and an erosion of dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. It is uncertain that there is osteomyelitis at this point. An assessment, dated 03/28/2023, Active Problems: Subacute osteomyelitis of left foot. Grade 2 ulceration is possibly due to arterial insufficiency on the left foot. Grade 1 ulceration dorsal right second toe. Plan: History and physical evaluation of lower extremities. I consulted wound care nursing to suggest a daily dressing bandage for the patient mainly will recommend Santyl collagenase with a dry dressing to be applied on the eschar ulcer on the medial aspect of the first metatarsal of the left foot. Betadine dressing can be applied to the right second toe. Patients will need vascular surgery for evaluation and treatment due to high suspicion of arterial insufficiency. Awaiting possible MRI of the lower extremity. Will follow as needed. An Infectious Disease consult, dated 03/28/2023: Skin: Has ulcer on the medial aspect of the left first metatarsal head. There is some minimal cellulitis present around the ulcer in the left foot. Right foot is also lateral fifth metatarsal head with large necrotic area and a small also behind it on the lateral aspect of right foot. Also, erosion on the dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. Also has right heel ulcer with cellulitis. Left gluteal area has a decubitus ulcer with no purulence. Assessment: Osteomyelitis of the left foot with chronic ulceration on the left metatarsal head area. Chronic ulcer of the left foot on the first metatarsal area medially and x-ray shows possible osteomyelitis. Ulcers of the left fifth metatarsal area necrotic. Some excoriation on the right second toe with cellulitis. Cellulitis of the bilateral feet. Right heel superficial ulceration with cellulitis. Peripheral vascular disease start ultra sound showing unable to visualize the left popliteal artery. Left buttock decubitus ulcer which is stag 2-3/ unstageable. Inpatient consult to Vascular Surgery, dated 03/29/2023. Reason for consultation: Atherosclerosis with bilateral foot ulcers. History: .Unclear duration. Non ambulatory. Severe contracture of left leg at the hip and knee. According to the family, the patient started having blisters of the feet a couple of months ago which progressed to gangrene. Assessment and plan Active Problems: Subacute osteomyelitis of left foot. Arterial duplex images were reviewed. CBC results reviewed .A findings concerning hemodynamically significant arterial occlusive disease with nonpalpable pedal pulses bilaterally. Bilateral lower extremity ulcers with finding concerning for osteomyelitis on the left x-ray. MRI pending. Had a discussion with the family over the phone. Severely limited functional capacity with contracture of the left leg. He is a poor candidate for any revascularization procedures. He cleared from my standpoint for foot debridement. If he does not heel, may end up needing AKA (above the knee amputation). Consider hospice eval if family is agreeable. 2. A review of the medical record revealed Resident #1 had resided at the facility less than a month and had a diagnosis of unspecified dementia. A review of the Hospital After Visit Summary Instruction Medication list revealed the following: Trazodone (psychoactive) 50 mg 1 tablet by mouth at night if needed for sleep dated 02/06/2023. A review of transcribed Physician orders revealed the following: Trazodone HCI Oral Tablet 50 mg give one tablet by mouth every 24 hours as needed for Depression Give at night dated 02/06/2023. A review of the Medication Administration Record (MAR) revealed from 02/06/2023 to 03/03/2023 Resident #1 had received Trazodone one time (02/14/2023) in 25 days for depression. Further review of Physician orders revealed the Trazodone was changed on 03/03/2024 to Trazodone 50 mg give one tablet by mouth one time a day for insomnia. A review of Medication Regimen Review (MRR) dated 02/13/2023 revealed the resident had an order for: Trazodone 50 mg po (every) q hours (hrs.) as needed (PRN) depression Recommendation: Please schedule this order. Rationale: Depression should not be treated PRN Physician/ Prescriber Response: Agree. Please schedule Trazodone to 50 mg at bedtime for insomnia dated 03/02/2023. On 04/20/2023 at 3:25 p.m. an interview was conducted with the Director of Nursing (DON) she confirmed she knew Resident #1. She said when she was admitted to the facility, she had orders for Trazodone. She stated, She did it at the hospital. She was unsure why the order was changed to routine, and why the diagnosis had changed to insomnia. She confirmed the medical record failed to reflect; the resident was having difficulty with sleeping. She stated, I can't see the MD even touching her medications without the family being notified. At 3:59 p.m. the DON said it was the Psychiatrist who had changed the Trazodone orders. On 04/20/2023 at 4:10 p.m. a phone interview was conducted with the facility Psychiatrist related to the change in Resident #1 Trazodone order. The Psychiatrist did not recall the resident at first. The Director of Nursing was present and referenced the Psychiatrist to the MRR change. The Psychiatrist confirmed she did not update the family on the medication change. The DON stated It was not the Psychiatrist responsibility to update the family. It is the facility's responsibility to notify the family of a change. She confirmed the medical record did not reflect the family was notified. A review of the facility's policy and procedures for Change in a Resident's Condition or Status, undated, documented the policy statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical / mental condition and / or status (e.g., changes in level of care, billing/payments, resident's rights, etc.). The policy interpretation and implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): a. Accident or incident involving the resident. b. Discovery of injuries from an unknown source. c. Adverse reaction to medication. d. Significant change in the resident's physical/ emotional/ mental condition. e. Need to alter the resident's medical treatment significantly. f. Refusal of treatment or medications, two or more consecutive times). g. Need to transfer the resident to a hospital/ treatment center. h. Discharge without proper medical authority; and/or i. Specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). b. Impacts more than one area of the president's health status. c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including (for example) information prompted by the Interact SBAR communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/ treatment center. 5. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status. 6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/ her medical care or nursing treatments. 7. The nurse will record in the resident's record information relative to changes in the resident's medical/ mental condition or status. 8. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. 31724

Based on interviews, photographic evidence, and record review, the facility failed to ensure accurate assessments of skin conditions were conducted to prevent worsening of wounds for one resident (#4) of six sampled residents. Findings included: A phone interview was conducted with Resident #4's family member. He stated on 02/18/2023, he had gone to the facility, and they told him Resident #4 had a wound on his left foot, he had looked at it and it looked like it was healing. He stated, on 02/19/2023, they called me again and told him about the wound. On 02/20/2023, he had gone to the facility and observed Resident #4 with a boot on, and he had spoken to Staff I, Licensed Practical Nurse (LPN) who said she did not know why the boot was on, but she would recommend removing it. On 03/19/2023, he stated he was called, and they told him Resident #4 had a wound on his buttocks. On 03/27/2023, he stated he visited, and he was concerned because the resident was always covered, and always in bed. He stated the resident had no boots on his foot and when he lifted the left foot, he saw all the black on the resident's foot. He stated he was upset and talked to the nurse to find out how it happened. He stated he asked to see the supervisor and was told the blackened area happened yesterday. He stated he also discovered the resident had a wound on his right foot. He stated the supervisor said he would tell the wound nurse. On 04/24/2023 at 2:18 p.m., Resident #4's family member was contacted by phone. He indicated photos that were provided were taken at the nursing home on 03/27/2023, the day before Resident #4 was transferred to the hospital. A review of the photos of Resident #4's left foot, showed blackened skin on the outer side of the left foot extended from the little toe almost to the middle of the foot. A blackened circle area approximately the size of a nickel on the same side was noted. On the inside of the left foot was another blackened circle area with pink open area, approximately the size of a quarter, located at the head of the first metatarsal. The right foot revealed on the top of the second toe was pinkened area with liquid residue present. A review of Resident #4's clinical chart revealed an admission of 07/2019. The clinical record revealed the resident was transferred to the hospital on 03/28/2023. The diagnosis list included: unspecified dementia, atherosclerotic heart disease of native coronary artery without angina pectoris; Type 2 Diabetes Mellitus with unspecified complications; hypertension; gastro esophageal reflux disease without esophagitis; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #4's Minimum Data Set (MDS) Annual Assessment, dated 03/07/2023, documented a score of 99, which revealed the assessment was not able to be completed for the resident. A review of Section G: Functional status, revealed the resident required extensive assistance for his Activities of Daily Living (ADLs), such as dressing, toileting, eating, locomotion, bed mobility, and transfer. A review of Section M: Skin conditions, revealed Resident #4 was at risk of development of pressure ulcers. Section M revealed the resident was identified not to have any unhealed pressure ulcers of Stage 1 or higher. Resident #4 was identified to have no venous or arterial ulcers present, and no indication of having any foot problems, i.e., diabetic foot ulcer or open lesion on the foot. A review of the quarterly MDS, Section M: Skin conditions, dated 12/07/2022, revealed a clinical assessment and formal assessment process was conducted to determine Resident #4's pressure ulcer risk. The assessment revealed Resident #4 was at risk of development of pressure ulcers, and the resident had no venous or arterial ulcers, no open lesions, rashes, skin tears or moisture associated skin damage. A review of Resident #4's Weekly Skin Checks was conducted for 02/04/2023 thru 03/25/2023, which reflected the following: 02/04/2023, the Site and Description boxes were blank; the comment section documented: 0 open area noted. 02/11/2023, the Site and Description boxes were blank; the comment section documented: 0 open area noted. 02/18/2023, the Site and Description boxes were blank; the comment section documented: Discolored areas still noticeable at bilateral feet. 02/25/2023, the Site and Description boxes were blank; the comment section documented: Discoloration still noticeable bilateral feet continue on skin prep. 03/04/2023, the Site and Description boxes were blank; the comment section documented: Discolored areas still noticeable bilateral feet. 03/11/2023, the Site and Description boxes were blank; the comment section documented: skin is clear. 03/19/2023, the Site: Left gluteal fold; Description: Small open area noted left ischium 1.5 x .75 inches. Cleansed with normal saline Medi-honey applied covered with gauze.; the comments section documented: DON notified. 03/25/2023, the Site: Left gluteal fold.; Description: Open area left ischium and discolored areas bilateral feet. The comments section: See Treatment nurse noted. A review of Resident #4's progress notes revealed the following: 02/11/2023, 14:18 (2:18 p.m.): Late entry, discolored areas noted right heel. Left foot bunion and outer pinky area and left inner ankle skin intact at all areas. Order for skin prep in place. (No documentation of physician notification or family notification.) 02/12/2023, 14:59 (2:59 p.m.): Started on skin prep bilateral feet. Podus boots in place. 02/12/2023, 15:30 (3:30 p.m.): Change in condition: Skin wound or ulcer. The physical assessment documented a skin evaluation, Discoloration; with a summary: skin check done discoloration noted. With the primary care provider feedback: Recommendation: skin prep 02/18/2023, 01:12 (1:12 a.m.): MD (Medical Doctor) notified of minimal swelling with light pink discoloration on the left foot along the side of the existing blister. Now new orders given at this time. Will monitor area for any changes and notify physician. 02/18/2023, 03:52 (3:52 a.m.): New order from physician for Keflex 500 mg (milligrams) bid (two times a day) x 7 (seven) days for blister/ skin infection on left foot. Family member notified; medication order placed with pharmacy. 02/21/2023, 11:48 (11:48 a.m.): Discontinue multipodus boots, r/t left foot blister. Resident continues with ABX (antibiotic) with no ill effect. MD in agreement, son called and updated with new order. 03/15/2023, 14:08 (2:08 p.m.): A care plan meeting was attempted with the POA (power of attorney) but got no response. The care plan meeting was held amongst the team. There are no changes with care. Resident eat meals with the assist group. Residents may be discharged with spouse to a facility with memory care or locked unit. Resident will remain a full code. 03/19/2023, 11:04: Change in condition: Skin wound or ulcer. The nursing observations: During skin check nurse noted the open area, started treatment. DON notified. The Primary Care Provider feedback: Recommendations: Continue with present TX (treatment), until assessed by TX nurse and Wound Doctor. (No family notification documented.) 03/21/2023, 13:15 (1:15 p.m.): Nutritional Evaluation: The evaluation indicated no recent lab drawn; the skin condition: Intact Other: Discoloration. 03/27/2023, 20:36 (8:36 p.m.): MD made aware of rapid declining wound to patient's left lateral foot. Family at bedside. Wound appears black in color and redness to exterior of the wound. No drainage or slough. Wound is dry. New order received for doppler, x-ray and labs due dx (diagnosis) of diabetes, and atherosclerosis. Family made aware of orders and treatment that is in place will continue as ordered by MD. 03/28/2023, 16:55 (4:55 p.m.): Change in condition: Skin wound or ulcer. Nursing observations, recommendations are: Send to ER (emergency room ) for eval (evaluation) d/t (due to) wound. Primary Care Provider Feedback: Recommendation: OK to send to ER for evaluation. New testing orders: Venous Doppler, X-Ray. 03/28/2023, 17:49 (5:49 p.m.): MD made aware of diagnostics new order made to send patient to ER for vascular calcification per X-Ray and rapid declining foot ulcer to rule out occlusion and osteomyelitis. Patient not responding to recent topical and abt treatment to the foot ulcer. Patient has history of dx, and x-rays also reveal osteoporosis. Family made aware patient discharged to (hospital). Report given to ER nurse. Patient is clean and dry at the time. [family member] states the patient's groin is red. This nurse as well as the floor nurse and paramedics observe perineal area is clean dry and free from redness, irritation, or breakdown at this time. A review of the doppler study, dated 03/28/2023, revealed the following: LT (left) arterial duplex unilat lower extreme (Duplex includes real time 2 D scanning & color Doppler): Impression: Mild to moderate atheromatous change. A review of the Radiology Interpretation, dated 03/28/2023, revealed the following: Left Foot complete: Osteoporosis and changes of chronic osteoarthrosis are noted. No fracture or dislocation can be seen. No acute findings noted. Impression: Osteoporosis and changes of chronic osteoarthrosis. Heel spur noted and degenerative changes seen throughout toes with vascular calcification noted. On 04/20/2023 at 1:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated for skin observations, the CNA will document if they did not see a new area, or if there is a new area. She confirmed the CNAs should document the latter information every day during the appropriate shift. The DON stated if the CNA observes a new area of skin impairment, the CNA tells the nurse, and the nurse conducts the assessment. The DON provided progress notes, dated 02/12/2023, which indicated skin wound ulcer, but no location or size. The DON stated the information should be on the skin assessment. The skin assessment was reviewed for this date, and she confirmed it was blank. The DON said, do not know, what the size of the skin wound ulcer was. On 04/20/2023 at 3:40 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated for a change in skin or skin impairment, she would expect the CNAs to let the nurse know. She stated We have protocols. We can apply Zinc. They always let me know. I look. Anything stageable, we get a wound consult. If the impairment was not there yesterday and there today, they let us know. We have weekly skin checks. If something is new, we are supposed to notify the doctor, the family and do an assessment. She stated most nurses do not put measurements on their skin checks. She stated, I was there when the DON called the [family member] on 03/27/2023, to let him know we were going to send him out to the ER (emergency room ) for a doppler. She stated she had seen the foot and the blackened area on the side of the foot, and they had done two arterial scans and a doppler, on 03/28/2023. A review of hospital records for Resident #4, dated 03/28/2023, documented a history of present Illness: This (geriatric) patient . Patient has hypertension and hyperlipidemia. The patient has chronic left and right foot wounds. Patient had bilateral lower extremity ultrasound that showed good flow. On evaluation the patient has a fifth digit infection on the left side with also (sic) and also on the medial aspect of the foot plus on the right side the second toe looks infected.The patient will be on Cefepime and Vancomycin. A further review of the hospital record indicated an Adult Nutrition Consult was conducted on 03/28/2023, the assessment: Pt (patient) previous NPO (nothing by mouth). Diet progressed by MD after pt seen. Pt non-verbal. No family present. Pt with multiple wounds present. Will order ONS (Oral Nutritional Supplements) to optimize oral intake and provide additional pro/call for wound healing. Interventions: 1. Continue current diet. 2. Recommend SLP (Speech-language pathologist) eval (evaluation) if pt having difficulty chewing/ swallowing. 3. Add Ensure Plus HP (High protein) TID (three times a day), 20 g (grams) pro (protein) per carton. 4. Monitor PO (by mouth) intake, labs/ elytes, BM and weight. A further review of the hospital record, a Podiatry Consult, dated 03/29/2023: On examination of lower extremities, the patient has atrophic skin bilaterally with an oval grad 1-2 ulceration on the medial aspect of the 1st metatarsal head of the left foot with a dense eschar which upon removal show a small opening with the droplet of pyogenic exudate but uncertain if he goes all the way to capsule certainly no bone exposure is seen. There is minimal erythema surrounding the ulcer site which measures about 1 cm in diameter and no other lesions are seen on the left foot. Again, the skin is atrophic, and the pedal pulses were barely palpable to nonpalpable due to nonpitting edema to the area no hair growth patterns of bilateral lower extremities. There is a small excoriation on the lateral fifth metatarsal head on the right foot and an erosion of dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. It is uncertain that there is osteomyelitis at this point. An assessment, dated 03/28/2023, Active Problems: Subacute osteomyelitis of left foot. Grade 2 ulceration is possibly due to arterial insufficiency on the left foot. Grade 1 ulceration dorsal right second toe. Plan: History and physical evaluation of lower extremities. I consulted wound care nursing to suggest a daily dressing bandage for the patient mainly will recommend Santyl collagenase with a dry dressing to be applied on the eschar ulcer on the medial aspect of the first metatarsal of the left foot. Betadine dressing can be applied to the right second toe. Patients will need vascular surgery for evaluation and treatment due to high suspicion of arterial insufficiency. Awaiting possible MRI of the lower extremity. Will follow as needed. An Infectious Disease consult, dated 03/28/2023 revealed the following: Skin: Has ulcer on the medial aspect of the left first metatarsal head. There is some minimal cellulitis present around the ulcer in the left foot. Right foot is also lateral fifth metatarsal head with large necrotic area and a small also behind it on the lateral aspect of right foot. Also, erosion on the dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. Also has right heel ulcer with cellulitis. Left gluteal area has a decubitus ulcer with no purulence. Assessment: Osteomyelitis of the left foot with chronic ulceration on the left metatarsal head area. Chronic ulcer of the left foot on the first metatarsal area medially and x-ray shows possible osteomyelitis. Ulcers of the left fifth metatarsal area necrotic. Some excoriation on the right second toe with cellulitis. Cellulitis of the bilateral feet. Right heel superficial ulceration with cellulitis. Peripheral vascular disease starts with ultra sound showing unable to visualize the left popliteal artery. Left buttock decubitus ulcer which is stag 2-3/ unstageable. An Inpatient consult to Vascular Surgery, dated 03/29/2023, revealed the following: Reason for consultation: Atherosclerosis with bilateral foot ulcers. History: .Unclear duration. Non ambulatory. Severe contracture of left leg at the hip and knee. According to the family, the patient started having blisters of the feet a couple of months ago which progressed to gangrene. Assessment and plan Active Problems: Subacute osteomyelitis of left foot. Arterial duplex images were reviewed. CBC results reviewed .A findings concerning hemodynamically significant arterial occlusive disease with nonpalpable pedal pulses bilaterally. Bilateral lower extremity ulcers with finding concerning for osteomyelitis on the left x-ray. MRI pending. Had a discussion with the family over the phone. Severely limited functional capacity with contracture of the left leg. He is a poor candidate for any revascularization procedures. He cleared from my standpoint for foot debridement. If he does not heel, may end up needing AKA (above the knee amputation. Consider hospice eval if family is agreeable. A review of the facility's Prevention of Skin Issues/ Pressure Injuries policy and procedures, undated, documented, the Purpose: The purpose of this procedure is to provide information regarding identification of skin issues/ pressure ulcer/ injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission for existing skin issues/ pressure ulcer/ injury risk factors. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity-any evidence of existing or developing pressure ulcers or injuries. b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin issues/ pressure injuries (i.e., no blanchable erythema/ rashes). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). c. Wash the skin after any episodes of incontinence. d. Reposition resident as indicated on the care plan. Moisture 1. Keep the skin clean and free of exposure to urine and fecal matter. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring/ documenting: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 3. Evaluate open areas (pressure / surgical areas) per MD orders.

Based on interviews and record review, the facility failed to ensure the development and implementation of a comprehensive care plan for two residents (#2 and #4) out of six sampled residents. It was determined the facility 1) Lacked evidence related to the development of, care and treatment of actual pressure ulcers and deep tissue injuries for Resident #2; and 2) Failed to implement interventions related to notifying representatives of a change of a condition and the prevention of pressure ulcers for Resident #4. Findings included: 1. On 4/20/2023 medical record review revealed Resident #2 was admitted to the facility on [DATE] for short term rehabilitation services. A review of the Advance Directives revealed the resident had a medical and financial decision maker during the time of his admission. A review of the admission diagnosis sheet revealed diagnoses including but not limited to, hemiparesis, heart Failure, heart disease, anxiety, depression, and history of pulmonary embolism. A review of the 10/2022 Physician's Order Sheet revealed Resident #2 was receiving hospice services. A review of the discharge summary and progress notes, dated 11/2/2022, revealed per Resident #2 and his spouse request, the resident was discharged from the facility and transferred to another Long-Term Care facility. A review of the previous hospitalization Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated with discharge date [DATE], revealed the resident did not have any pressure wounds, and that his skin was clear. A review of the Admission Minimum Data Set (MDS) assessment, dated 8/24/2022, revealed the following: Cognition/Brief Interview Mental Status or BIMS score - No score indicated. However, the assessment indicated the resident had Moderately Impaired decision-making skills; Skin Conditions - Checked as at risk for pressure ulcers, did not have any unhealed stageable pressure ulcers during time of admission, did not have any stageable pressure ulcers upon admission, and did not have any deep tissue injuries at time of admission. A review of the Discharge MDS assessment, dated 11/2/2022, revealed the following: Cognition/BIMS score - Not score indicated. However, the assessment indicated the resident had Moderately Impaired decision-making skills; Skin Conditions - Not Checked as at risk for pressure ulcers, checked as having (1) unstageable deep tissue injury. The assessment did not identify any stageable pressure ulcers upon discharge. A review of the Nursing Admission Assessment, dated 8/16/2022, revealed; Section O; Skin assessment, not checked for presence of wounds. Indicating skin was clear with no wounds. A review of the following skin assessments/skin sheets revealed the following. 1. Skin check sheet dated 9/3/2022 - no new skin issues. 2. Skin check sheet dated 9/10/2022 - no new skin issues. 3. Skin check sheet dated 9/17/2022 - no new skin issues. 4. Skin check sheet dated 9/24/2022 - no new skin issues. 5. Skin check sheet dated 10/1/2022 - no new skin issues. 6. Change of Condition dated 10/5/2022 - Skin wound or ulcer, and rash, condition of skin just noted, representative and MD (medical doctor) notified 10/25/2022. 7. Skin check sheet dated 10/8/2022 - Right rear skin tear, no new more skin problem. 8. Skin issues in place with treatment. 9. Skin check sheet dated 10/18/2022 - Wound right Outer foot 2.0 x 1.5 x 0.1 cm: Blister right outer foot 2.5 x 2.0, no odor no drainage. 10. Change of Condition dated 10/18/2022 - Other change of condition with notes - Blister and wound in right outer foot, representative and MD notified 10/18/2022. 11. Skin check sheet dated 10/19/2022 - Right lower back Pressure ulcer (in house acquired) Stage III 2 x 3 x 0.1 cm identified on 10/19/2022 with intervention to float heels and reposition x two hours every shift. 12. Skin check sheet dated 10/19/2022 - Right Distal Lateral Foot DTI (deep tissue injury) 2x2, identified on 10/19/2022 with interventions to float heels and reposition x two hours every shift Skin Check sheet dated 10/25/2022 - TX (treatment) in progress to right foot and right lower back. No other issues noted. 13. Wound evaluation dated 10/26/2022 - Right lower back pressure ulcer (in house acquired) Stage III 1.5 x 2.2 x 0.1 cm and identified on 10/19/2022 with interventions to float heels and reposition x two hours every shift 14. Wound evaluation dated 11/2/2022 - Right lower back pressure ulcer (in house acquired) Stage III 1.2 x 1.8, x 0.1 cm. A review of the [company name] Wound Physicians Initial Wound Evaluation and Management Summary, dated 10/19/2022, revealed Resident #2 has multiple wounds. The assessment continued to indicate Resident #2 had wounds identified to include: Unstageable Deep Tissue Injury (DTI) of the Right, Proximal, Lateral Foot; Unstageable DTI of the Right, Distal, Lateral foot; Stage III Pressure wound of the Right lower back. A review of the [company name] Wound Physicians Initial Wound Evaluation and Management Summary, dated 11/2/2022, revealed Resident #2 has multiple wounds. The assessment continued to indicate Resident #2 had identified wounds to include: Unstageable DTI of the Right, Proximal, Lateral foot; Unstageable DTI of the Right, Distal, Lateral foot; Stage III Pressure wound of the Right, Lower back; Unstageable DTI Coccyx. It was determined through review of the assessments, that Resident #2 developed pressure ulcer and deep tissue injuries around 10/5/2022 - 10/19/2022 and continued to be treated through 11/2/2022 upon Resident #2's discharge date . A review of the Physician's Order Sheet, dated for the month of 10/2022, revealed the following: a. Treatment to Left Buttocks as needed with an order date of 10/19/2022. b. Wound care to cleanse DTI of the Right lateral foot with an order date of 10/19/2022. c. Wound care to the Right lower back with an order date of 10/20/2022. d. Wound treatment to Right outer foot with an order date of 10/18/2022. e. Wound treatment to blister on Right outer foot with an order date of 10/18/2022. f. Wound treatment to cleanse DTI of the right, proximal foot with an order date of 10/22/2022. A review of the 10/2022 Medication Administration Record (MAR) revealed all wound orders were documented as completed per the order with no blank spaces that would indicate the treatment was not completed. These orders were verified and also completed with treatment for the first two days of 11/2022, up until the resident discharged out from the facility. A review of the last care plans prior to Resident #2 discharging from the facility, with an initiated date of 8/17/2022, and with a next review of 11/27/2022, revealed the following pertinent problem areas: - admitted as short-term placement and with interventions in place as reviewed. - Impaired cognitive functions and impaired thought process with interventions in pace as reviewed. - Resident needs assist with ADL (activities of daily living) care related to multiple factors including weakness and decreased mobility and status post recent hospitalization with interventions in place as reviewed. - Risk and use of anti-anxiety medications with interventions in place as reviewed. - Resident is receiving palliative care Hospice care with interventions in place as reviewed. - Risk for skin impairment r/t neuropathy, use of ac, weakness, and decreased incontinence with interventions in place. Care plan problem area indicated it was initiated on 8/17/2022 and revised on 10/14/2022. A review of Resident #2's entire care plan did not indicate any problem areas, goals, and interventions to include actual and current wounds. The care plan only identified the resident was at risk for skin impairment. On 4/20/2023 at 2:57 p.m. Staff B, Minimum Data Set (MDS) Coordinator was not available at the facility for in person interview, however, the Nursing Home Administrator (NHA) was able to set up a telephone interview with her. At 3:00 p.m. a telephone interview with Staff B, along with another MDS coordinator Staff A, who was reviewing the electronic record for Staff B, revealed they both knew of and remembered Resident #2. Staff A and Staff B confirmed Resident #2 was admitted to the facility on [DATE] and discharged to another facility per spouse request on 11/2/2022. Staff B explained through medical record review, to include Wound Care Assessments, and Daily and Weekly skin sheets, it appeared the resident developed several wounds. Staff B stated the wounds were: an Unstageable DTI (deep tissue injury) of the Right, proximal, lateral foot; an Unstageable DTI of Right, distal, lateral foot; and a Stage 3 Pressure Wound of the R lower back. Both Staff A and B confirmed the resident had Deep Tissue Injuries and a Stage III Pressure ulcer, which were all developed after his original admitted . Staff A pulled up the wound records on the electronic medical records and confirmed it to Staff B, who was on the telephone. Staff B revealed she did remember Resident #2 developing wounds and he had been assessed, ordered for treatment, and provided with treatment for those said wounds. Staff B and A confirmed when a resident develops an in-house acquired pressure ulcer the care plan team meets and discusses the wounds. Staff B confirmed the wounds should be carried over to the care plans and created as an actual wound problem area with interventions to decrease and reduce the risk of further wounds. Staff B reviewed the last care plans, with a next review date of 11/27/2022, and stated Resident #2 was planned with at risk for skin impairment, rather than having actual skin impairment to include pressure ulcers and deep tissue injuries. Both Staff A and B confirmed the care plan only related to risk for skin impairment and not the actual wounds. Both Staff A and B explained the actual pressure ulcers and deep tissue injuries should have been care planned as an actual problem area with interventions within twenty-four hours of identifying the problem. On 4/20/2023 at 3:30 p.m. an interview with the Director of Nursing confirmed through review of Resident #2's medical record, the resident did develop deep tissue injuries and a pressure ulcer after he was admitted to the facility. She further confirmed though the resident was assessed for, ordered for treatment, and with treatment completed daily, the care planning team did not update and revise, nor develop care plan problem areas with relation to the actual wounds. She confirmed the care plans only had care plan problem areas related to risk for skin impairment. The Director of Nursing stated the care plans should have been updated/developed within a week, but in this case, it did not happen. It was found that the facility did not develop and revise the skin care plan for at least twenty-four days. On 4/20/2023 at 3:45 p.m. the facility's Nursing Home Administrator provided the Care Planning - Interdisciplinary Team policy and procedure, not dated, for review. The policy stated, our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The policy interpretation and implementation section revealed: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician. b. The Registered Nurse who has responsibility for the resident. c. The Dietary Manager/Dietitian. d. The Social Services Worker responsible for the resident. e. Therapists (speech, occupational, recreational, etc.), as applicable. f. The Director of Nursing (as applicable). g. The Charge Nurse responsible for resident care. 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 2. A review of Resident #4's clinical chart revealed an admission of 07/2019. The clinical record revealed the resident was transferred to the hospital on 03/28/2023. The diagnosis list included: unspecified dementia, atherosclerotic heart disease of native coronary artery without angina pectoris; Type 2 Diabetes Mellitus with unspecified complications; hypertension; gastro esophageal reflux disease without esophagitis; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #4's Weekly Skin Checks reflected the following: 03/19/2023, the Site: Left gluteal fold; Description: Small open area noted left ischium 1.5 x .75 inches. Cleansed with normal saline Medi-honey applied covered with gauze.; the comments section documented: DON (Director of Nursing) notified. 03/25/2023, the Site: Left gluteal fold.; Description: Open area left ischium and discolored areas bilateral feet. The comments section: See Treatment nurse noted. A review of Resident #4's progress notes, dated 03/19/2023, 11:04: Change in condition: Skin wound or ulcer. The nursing observations: During skin check nurse noted the open area, started treatment. DON notified. The Primary Care Provider feedback: Recommendations: Continue with present TX (treatment), until assessed by TX nurse and Wound Doctor. A review of Resident #4's clinical record reflected no evidence the Wound Doctor had reviewed Resident #4's open area on his left ischium from the date of discovery, 03/19/2023 through the date of his discharge on 03/28/2023. On 04/20/2023 at 12:03 p.m., a request for documentation of Wound Doctor visits for Resident #4 was requested from the Director of Nursing (DON). No documentation was provided by the facility during the survey. A review of Resident #4's Care Plan revealed the following: Focus: Resident #4 is at risk for skin impairment r/t diabetes, incontinence, use of anticoagulant/ antiplatelet medications, weakness/ decreased mobility, initiated 11/01/2022. Goal: The resident will be free from any new skin impairment through the review date, initiated 11/01/2022. Interventions included: Skin checks weekly and as indicated. Report any s/s of skin breakdown to MD/ wound team as indicated, initiated 11/01/2022. Focus: Resident #4 has a stage 2 pressure ulcer to left ischium, initiated 03/21/2023. Goal: The resident's pressure ulcer will show signs of healing as evidenced by decrease in size, improved appearance, and be free from infection by/ through review date, initiated 03/21/2023. Interventions: Administer medications and treatments as ordered by the MD (Medical Doctor), initiated 03/21/2023. Complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for s/s (sign and symptoms) of infection. Report changes to MD as indicated, initiated 03/21/2023. Educate the resident/ family/ caregivers as to causes of skin breakdown; including transfer/ positioning requirements; importance of taking care during ambulating/ mobility, good nutrition, and frequent repositioning, initiated 03/21/2023. Medicate prior to wound treatments if indicated. Notify MD for unrelieved pain, initiated 03/21/2023. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, initiated 03/21/2023. Wound Care MD/ APRN consult as ordered/indicated, initiated 03/21/2023. On 04/20/2023 at 9:05 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She stated she was providing wound care services. She stated the wound doctor comes to the facility on Wednesdays and the treatment nurse rounds with him. She stated he was timely with the uploads of the wound service, usually the same day or the following day. She stated if a new wound were identified, she would tell the house doctor and she would get a consultation order for the wound doctor to see the resident. On 04/20/2023 at 3:22 p.m., an interview was conducted with Staff H, Certified Nursing Assistant (CNA). She stated she did recall Resident #4. She stated she worked with him, but not every day. She stated, I was assigned a little down the hall, sometimes if someone would call off, my assignment would include him. She said, his butt had a little thing on it, redness in the area. The nurse put clear cream on it and then a dressing on it. It was a 4 x 4 soft material. She stated she could not indicate a time, but she said he had the redness, which had treatment from Staff J, (the nurse), and it was looking better before he left. She stated, I saw a pillow for positioning. He was contracted; a Hoyer lift; he was totally cared for. I would cushion him with a pillow; change him every 2-3 hours. On 04/20/2023 at 3:40 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated for a change in skin or skin impairment, she would expect the CNAs to let the nurse know. She stated We have protocols. We can apply Zinc. They always let me know. I look. Anything stageable, we get a wound consult. If the impairment was not there yesterday and there today, they let us know. We have weekly skin checks. If something is new, we are supposed to notify the doctor, the family and do an assessment. Staff I stated for a wound consult, It is easy. We just put them on the list. She stated the reason for the wound consult is to see what treatment is best for that area. Staff I reviewed Resident #4's clinical chart and confirmed she was not able to find a wound consult visit documented in the clinical chart for 2023. On 04/20/2023 at 1:30 p.m., the DON provided a sheet of paper which documented: Wound consult timeline for [Resident #4] Wound consult placed on 03/26-Sunday. Patient sent out 03/28/2023-Tuesday. Wound MD comes in on Wednesday. A review of Resident #4's hospital records, dated 03/28/2023, indicated an Infectious Disease consult, dated 03/28/2023, which included: Skin: . Left gluteal area has a decubitus ulcer with no purulence. Assessment included: Left buttock decubitus ulcer which is stag 2-3/ unstageable. A review of the facility's Prevention of Skin Issues/ Pressure Injuries policy and procedures, undated, documented, the Purpose: The purpose of this procedure is to provide information regarding identification of skin issues/ pressure ulcer/ injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission for existing skin issues/ pressure ulcer/ injury risk factors. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity-any evidence of existing or developing pressure ulcers or injuries. b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin issues/ pressure injuries (i.e., non-blanchable erythema/ rashes). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). c. Wash the skin after any episodes of incontinence. d. Reposition resident as indicated on the care plan. Moisture 1. Keep the skin clean and free of exposure to urine and fecal matter. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring/ documenting: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 3. Evaluate open areas (pressure / surgical areas) per MD orders. 22481

Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment related to not maintaining the kitchen ceiling in one of one kitchen, repairing of holes in the walls of three resident rooms (#140, #145 and #181), and a stained floor, walls and privacy curtain and broken furniture in one resident room (room [ROOM NUMBER]) out of a total of 64 resident rooms. Findings included: 1. On 01/09/23 at 10:02 a.m., an initial tour of the kitchen was conducted. Three ceiling tiles were observed cracked and chipped in the area near the dish washing machine. In addition, multiple ceiling tiles above the food prep area were observed with an excessive amount of black buildup (Photographic Evidence Obtained). On 01/10/23 at 9:30 a.m., the Nursing Home Administrator reported they have had a Quality Assurance and Performance Improvement (QAPI) in place for building repairs since August 2022 and the kitchen ceiling was on the list. He stated the ceiling tiles were on back order due to the hurricane. The ceiling tiles in the kitchen were cleaned last night, stated the Nursing Home Administrator. On 01/11/23 at 11:08 a.m., the ceiling tiles were observed cleaned and repaired. The Certified Dietary Manager (CDM) confirmed there was a concern with the ceiling tiles, and they could have cleaned the tiles prior to survey. 43453 2. During a facility tour on 01/12/23 at 9:10 a.m., an observation was made of room [ROOM NUMBER]. The observation revealed a dead insect on the floor by Bed A's bedside table. Further observation revealed Bed A's privacy curtain was noted stained with brown marks. An observation was made of dark brown matter spattered on the floor by Bed B and on the adjacent wall. The brown matter was splashed on the resident's clothes that were in a bag by the bed. In addition, during this observation Bed B's dresser was noted broken and not closing properly with clothes spilling out. A trash can by the door was noted overflowing with trash and used gloves. The floor was noted with dirt, dust, and papers. (Photographic Evidence Obtained) On 01/12/23 at 10:11 a.m., an interview was conducted with Staff G, Housekeeping / Floor Technician. Staff G reviewed the photographic evidence and said, That looks really bad. I will take care of it now. Staff G stated resident rooms should be cleaned promptly, at least daily and as needed. Staff G stated he did not know why the aide did not at least pick up the mess off the floor and let Housekeeping know. Staff G stated the brown substance on the floor looked like bowel matter. Staff G stated it was unacceptable. Staff G stated he would go to room [ROOM NUMBER] and clean it right away. On 01/12/23 at 1:34 p.m., an interview was conducted with the Director of Maintenance (DOM). The DOM looked at the room appearance and stated the room was not acceptable. It was not clean per their standards. The DOM said, It should have been cleaned right away. The DOM reviewed the photographic evidence and said, It looks like feces, residents should not have feces on the floors and walls. The DOM stated he expected resident rooms to be maintained in a clean and sanitary manner. On 01/12/23 at 1:48 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the resident in room [ROOM NUMBER] Bed B chewed tobacco and spits it on the floor and walls. The NHA reviewed the resident's care plan which had no documented evidence of on-going concerns with spitting tobacco chews or spitting on the floor. The care plan did not show interventions to address the concern. The NHA stated they would put a plan in place, give the resident a spit bottle and/or a trash can to spit in. The NHA stated he would have housekeeping staff go into the room three times a day to maintain a sanitary environment. The NHA reviewed photographic evidence and stated he would have housekeeping take of it. 40775 3. An observation was conducted on 1/12/2023 at 8:23 a.m. in resident room [ROOM NUMBER]. The window side of the room near Bed B contained four unpainted drywall repair areas. Moderate built up areas of hardened drywall compound were observed on the patched areas of the walls. An observation was conducted on 1/12/2023 at 8:30 a.m. in resident room [ROOM NUMBER]. The window side of the room near Bed B contained a large unpainted drywall repair area to the right of the window. 37999 4. An observation was made on 1/12/23 at 1:50 p.m. of the wall behind the resident's motorized wheelchair in room [ROOM NUMBER]. The drywall behind the chair had previously been patched and left unfinished, and a hole in the drywall was observed behind the wheelchair near the resident's dresser. The resident stated the facility was aware of the issue (with wall) and that it happened when the aides tried to park the wheelchair. During the observation the plastic corner protector next to the resident's bathroom was attached to the wall using green tape. (Photographic Evidence Obtained)

Based on observation, record review, and interview, the facility, 1. failed to ensure blood pressures were monitored adequately for a period of three months for one resident (#40) of five sampled residents, and 2. failed to ensure one resident (#98) receiving antibiotic treatment had a diagnosis listed, to indicate the purpose of the treatment of four residents reviewed for a UTI (urinary tract infection) diagnosis. Findings included: 1. A review of the Admission Record revealed Resident #40 was initially admitted into the facility on [DATE] with a diagnosis that included but was not limited to hypertension. A review of the Order Summary Report with active orders as of 11/01/22 indicated the following order: Hydralazine HCL Tablet 25 MG (milligram)- Give 25 mg by mouth four times a day for hypertension, start date 9/25/22. Hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. A review of the Medication Administration Record (MAR) for November 2022, December 2022, and January 2023 revealed the medication was administered four times a day from 1/1/23 - 1/11/23, 12/1/22 - 12/31/22 and 11/1/22 - 11/30/22. The MARS did not reflect blood pressures were checked per order. A review of the Weights and Vitals Summary, dated 1/11/23, for blood pressures revealed the following blood pressures taken from 11/1/22 to 1/11/23: 01/06/23 - 131/82 01/04/23 - 110/51 12/04/22 - 128/71 11/30/22 - 128/62. The care plan related to hypertension initiated on 09/27/22 included the following intervention: monitor vital signs. On 01/11/23 at 5:15 p.m., the Director of Nursing (DON) confirmed blood pressures were not being checked per orders. She stated the blood pressures should have been checked four times per day. 43453 2. On 01/09/23 at 2:40 p.m., an interview was conducted with Resident #98's Responsible Party. The Responsible Party stated the resident had a UTI infection and he was not well. Review of the Admission Record for Resident #98 showed the resident was admitted to the facility on [DATE]. Review of physician orders for Resident #98, dated 1/10/23, showed Resident #98 was prescribed Bactrim DS tablet 800-160 mg, give 1 tablet by mouth two times a day for infection for 7 days. Orders initiated on 1/5/23 and with an end date of 1/12/23 showed the resident was being treated for an infection but did not indicate the diagnosis reflecting why the resident was receiving the antibiotic treatment. Review of the Medication Administration Record (MAR) for January 2023 for Resident #98 showed the antibiotic [Bactrim DS tablet 800 - 160 MG), was administered two times a day for an infection for seven days. The MAR did not show the diagnosis. On 01/10/23 at 12:11 p.m., an interview was conducted with Staff D, Registered Nurse (RN) assigned to Resident #98. Staff D stated Resident #98 was taking antibiotic Bactrim. Staff D reviewed the MAR and said, It says infection, I don't know what infection it is specifically, but the doctor usually prescribes it for UTI. Staff D stated he has administered the antibiotics for two days this week. He stated he did not review what the infection was for. Staff D reviewed the physician orders and the MAR and stated he was not sure exactly what the infection was but, he could look at the labs. Staff D reviewed the labs and stated the resident has a UTI according to labs that were obtained on the 1/3/23 with orders to administer antibiotics for 10 days. Staff D stated the doctor's orders should be specific. Staff D said, It should say for UTI. They need to put in the order clearly. It should state the actual diagnosis not just infection. Staff D stated he would confirm with the physician. On 01/10/23 at 12:27 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nurse who received the orders should have put in the diagnosis. The ADON said, It should not just say infection. It should indicate what the infection is. The nurse put it in wrong. The ADON stated she would follow-up. A follow up was conducted on 01/10/23 at 4:51 p.m., with the Director of Nursing (DON). The DON stated the expectation is for the diagnosis to be listed in the orders, the MAR, and the actual medication label.

Based on record review and interview, the facility failed to provide the services and oversight necessary to ensure safety and well- being and prevent neglect for two (#3, #4) of fourteen residents reviewed for accidents and supervision. Resident #3 sustained a fall that resulted in subsequent death. Resident #4 who was documented as actively dying and having terminal restlessness, was found on the floor alone in a puddle of blood and subsequently died on the floor of her room. The facility chose to discontinue one to one (1:1) constant supervision around the clock for Resident # 3, an [AGE] year old long term care resident with [DIAGNOSES REDACTED]. The facility chose to reduce the level of supervision from one to one to every 15 minute checks, which only required staff to observe the resident at least every fifteen minutes. The resident fell sustaining a subarachnoid hemorrhage within 12. 5 hours of the one to one supervision being discontinued. The facility ' s licensed nurse failed to increase the level of supervision to ensure Resident #3 ' s safety and well-being, in spite of the resident ' s attempt to get out of bed on her own and documented restlessness and impulsivity, instead leaving her alone in the hallway where she attempted to rise and fell , hitting her head, and sustaining a subarachnoid hemorrhage leading to her subsequent death. The facility failed to provide care and services to prevent neglect for Resident #4 who was reported as actively dying, restless and anxious. The facility ' s licensed nurses were aware of the resident ' s condition and reported that she had tried to get up on her own yet they failed to document any attempts to alleviate her symptoms and provide comfort and supervision to Resident # 4. The resident was found on the floor, alone, next to her bed, with her head on the metal frame of the over bed table and a pool of blood under her head. The resident died on the floor of her room with emergency services present. Past Non-Compliance at the Immediate Jeopardy level was identified on [DATE] as occurring on [DATE]. The Administrator was notified on [DATE] at 6:10 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings included: 1. A phone interview was conducted with a family member of Resident #3, on [DATE] at 10:55 a.m. She stated that her family member, Resident #3, had been on 1: 1 supervision since the beginning of her stay and was on it up until the day she fell . She stated the Risk Manager called her on [DATE] about decreasing the 1:1 supervision to every 15 minute checks. The Risk Manager told the family member that she had done time studies and evaluations and observed the resident for a half an hour. She stated she told the risk manager she didn ' t like it but she couldn ' t stop her from doing it and that it was basically a done deal when she called me. She stated she asked the risk manager, do you really have to do this? and the Risk Manager responded to her, It's time to do it. She stated she was told the observation of Resident #3 was for 30 minutes while Resident #3 was at the nurse ' s station. She stated that if the observation had been made when Resident #3 was left alone and if it had been extended 12- 13 hours, they probably would have made a different decision because she was getting up. The family member stated that the Risk Manager called her again that day to tell her that there was now a lap tray. She stated, she knew I was concerned, I was worried like crazy. She stated that the next call she received was around 1 ish, the next morning ([DATE]) and it was the nurse telling her that Resident #3 was up late, restless, trying to get out of bed and that she put her in her wheelchair with the lap tray on her and put her in the hallway. She stated the nurse told her she went into another resident's room, heard noise in the hallway and found Resident #3 out of her wheelchair on the floor, across the hall and that she had reinstituted 1:1 care. The family member stated that the description given to her of Resident #3's behavior that night flew in the face of the lack of impulsiveness that the Risk Manager observed earlier in the day. The family member stated that Resident #3 had suffered a subarachnoid hemorrhage due to the fall and the physician didn ' t think she would make it as she was not responding and could not protect her airway. She stated she and other family members wanted to give the resident every opportunity to recover but she progressively didn't come out of it and there was so much brain damage from the hemorrhage. She stated, it was horrible, she was such a sweet lady, she was going through hell, she wouldn ' t have wanted this and she and other family members made the decision to take her off the ventilator. She stated She didn't make it. The family member stated 1:1 saved her life for as long as they did it. It was such a shock, she had other comorbid conditions but we weren ' t expecting this. The decision to take her off the one to one care and the lack of common sense when she tried to get out of bed and wouldn't keep the lap tray on was a formula for disaster, it didn't need to happen, and it shortened her life. Record review for Resident # 3 revealed that she was admitted to the facility on [DATE]. Review of the Client [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. According to www.PDR.net (Physician's Desk Reference) [MEDICATION NAME] is an Antiplatelet agent and side effects include increased risk of bleeding. The brand name for [MEDICATION NAME] is [MEDICATION NAME]. Record review revealed that Resident #3 sustained two falls in early 2015: on [DATE] and [DATE]. The resident was placed on one to one supervision in [DATE] and remained on one to one supervision from [DATE] until approximately 10:00 a.m. on [DATE]. Review of an annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a score of 3 (indicating Severe Cognitive Impairment) on the Brief Interview for Mental Status (BIMS) assessment. The resident was coded as needing extensive assistance of two persons for bed mobility and transfer, extensive assistance of one person for ambulation and total dependence for locomotion. Balance during transition and walking was coded as not steady, only able to stabilize with human assistance and the resident utilized a wheelchair for locomotion. Review of a Summary of Plan of Care, completed by a registered nurse on [DATE] revealed: Provide ½ side rails x 2 as enabler, geo mattress, w/c cushion, off load heels when in bed, provide 1: 1 increased observation 7 days/ week by facility staff due to impulsiveness /[MEDICAL CONDITION].Speech is clear but she appears confused and does not answer my questions appropriately . Requires 1: 1 supervision ,[DATE] due to impulsiveness and poor safety awareness. The Narrative summary includes Transfers with 1 person assist. Uses the w/c for mobility and it is propelled by staff. Review of Care plans for Resident #3 revealed a care plan, dated [DATE] and last reviewed [DATE] for a problem of risk for falls/injuries related to: [MEDICAL CONDITION], Decreased Activities of Daily Living (ADL's), Impaired Hearing, Impaired Memory, Impaired Vision, Unsteady Gait, and history of falls. Goals were listed as Will have as close to no falls possible by managing risk factors, if fall occurs, will have minimal injuries related to falls through next review. Fall risk Score 90 = High risk. Interventions included : Remind not to stand without assistance or use of assistive device if utilized; Use gait belt when helping to ambulate/transfer; Instruct/reinforce safety measures with ( resident )/ family such as transfer techniques, proper foot wear, locking wheelchair; Keep call light within reach; Encourage to ask for assistance as needed; Falling precautions program: if fall score is 25 or higher will use yellow wrist band; Monitor for changes in ADL's Cognition, Behavior, Mood and Medications for Potential Risk Factors; Staff will be responsive to individual hearing, vision or communication concerns (keep room and hallways free from hazardous objects/clutter, adequate lighting, reduction of background noise); Keep bed in lowest position to the floor when care is not being rendered and lock bed wheels at all times. A new care plan was written [DATE], when the resident was changed from 1: 1 supervision to every 15 minute checks, which listed a problem of Is in need of Q (every) 15 minute checks around the clock. Staff to resident assignment for closer supervision, monitoring and/or observation reference to but not limited to: impulsiveness at times. The goal was Will have no adverse outcomes/injuries through next review date. The interventions were not revised to reflect the change of level of supervision from 1:1 to Q 15 minute checks. Interventions still included The staff member assigned to the q 15 minutes around the clock checks will accompany the resident at all times (including bathing, showers, meals, toileting and off - unit activities). Resident will be within arm's reach at all times, even while sleeping; The staff member assigned to Q 15 minutes checks around the clock will not leave the resident at any time without a replacement staff member in place (breaks, meals, restroom, change of shift). The resident will not be left alone at any times; Staff member performing Q 15 minute around the clock will report to nurse any behaviors or changes in condition immediately; Try alternative measures to encourage relaxation and or provide distraction. In the assessment section of Resident # 3's record was a form, dated [DATE], entitled Evaluation of Need for Specialized Supervision, Observation and/or Monitoring, completed by the Risk Manager. Review of the form revealed yes responses were checked for the resident in reference to Is the resident non- adherent to safety interventions? and Does the resident have any other socially inappropriate behavior that poses a risk to self or others (i.e. public disrobing, rummaging in other ' s belongings, etc.?) A narrative comment revealed Resident who has extreme impulsivity will stand unassisted and attempt to walk & falls. She is unable to be left unattended so she is currently on 1: 1. Summary of findings and recommendations revealed Continue 1: 1 supervision and there were checkmarks for 1: 1 Nursing Staff Supervision Around the Clock. Review of the record revealed that Resident # 3 remained on 1: 1 supervision after this assessment until another assessment was completed seven days later. Review of an Evaluation of Need for Specialized Supervision, Observation and/or Monitoring dated [DATE] revealed a yes response for the question Is the resident non - adherent to safety interventions? Review of the narrative comments revealed Resident currently on 1: 1 supervision. She has had minimal needs of redirection as per 1: 1 supervision monitoring sheets. Evaluation conducted on [DATE] from 9: 30 -10: 00, Zero impulsive movements noted at this time. Will call MD (Medical Doctor) and suggest Q 15 minutes check around the clock to see if we can reduce the 1:1. Tools used: Observation sheets over 2 months, staff interviews, current assessment. Summary of Findings and Recommendations revealed Resident noted during a 30 minute observation period to have zero impulsive moments. 11 to 7 staff reporting zero attempts to rise at night and per 1:1 observation sheets she has moments of needed redirection that are successful. Will attempt reduction of 1:1 to Q 15 minute checks if MD agrees. Date physician notified: [DATE]. Physician orders [REDACTED]. Start Q 15 minute checks around the clock and may not be in room alone while up in wheelchair. Review of Nurse's notes in the resident's chart revealed an entry signed by the Risk Manager, for [DATE] at 10:00 a.m., which stated, Resident observed for possibility of decrease from 1:1 to Q 15 minute checks. Per log book, has minimum episodes of impulsivity and when she does redirection is + (positive). Resident sitting at nurses station up in wheelchair sitting well speaking with staff and residents that pass by. Zero moments of impulsivity. Spoke with POA (Power of Attorney) who agrees with reduction to Q 15 minute checks, MD agreed as well. Order noted to D/C 1:1, Start Q 15 minute checks ATC (around the clock). Possible for activity tray as resident likes books and magazines and a lap tray would facilitate this. Will Monitor. A second Nurse ' s note, written by the Risk Manager and dated [DATE] at 2:00 p.m. revealed, Full lap activity tray added to promote independent activities while up in wheelchair, MD and family aware. A Physical Restraint Elimination Assessment form was completed by the Risk Manager on [DATE]. Instructions on the form indicate Restrained individuals should be reviewed AT LEAST QUARTERLY to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or a total restraint elimination. For each category listed below, assess the resident by circling the corresponding score that best describe his/ her current status in the appropriate assessment column. Add the column of numbers to obtain the score. Review of the responses on the form revealed that responses were circled for: Ambulation - Ambulates with assist of two, Weight Bearing - full weight bearing, Sitting balance - leans to a side, forward, backward and slides down. ADLS - Requires total assist of two Physical Limitations - History of falls Vision status - adequate with glasses/without glasses Orientation - Disoriented (x 2 spheres) Comprehension - Directions must be frequently repeated Behavior/ Mood - Exhibits / Expresses fears or anxieties Activity Participation - Participates with assistance Medication Therapy - Not taking any chemical restraint. The total score was recorded as 18 and the scoring directions indicated a score of 0 - 20 was a Priority Candidate. Review of the assessment revealed: 1. Candidate Status as determined by Total Score on reverse - checked as Priority. 2. Candidate for restraint reduction or elimination program - choice of yes or no check box, no response was documented If yes, Date program to start: [DATE] Action Plan: Not a Restraint. 3. Additional Comments: This is an Activity tray that resident can remove. Review of physician telephone orders for [DATE] revealed an order with no time noted for 1. D/C all orders r/t 1: 1 Supervision. 2. Start Q 15 minute checks ATC. (Around the Clock) A second order with no time noted, also dated [DATE], stated Resident may have an Activity Full Lap tray to promote independence with activities. Check Q 30 minutes and remove Q 2 hours and PRN (as needed) for Group Activities, Meals, ADLS and Toileting. Review of documentation for Q 15 minute checks for Resident #3 for [DATE] revealed that from 9:30 a.m. to 8 p.m., the resident was noted to be at the Station 1 Nursing Station the majority of the time. At 8: 15 p.m., she was noted to be in the bathroom and from 8:30 p.m. to 11 p.m., she was documented as being in bed. Documentation commencing from 11:15 p.m. to 11:30 p.m. revealed the resident ' s location was noted to be up in wheelchair (W/C). From 11:45 p.m. on [DATE] to 12:30 a.m. on [DATE], the resident ' s location was documented as W/C A Hall. At 12:45 a.m., Staff B, the Certified Nursing Assistant (C.N.A.) who provided care for this resident during the 11 p.m. to 7 a.m. shift on [DATE], had documented the resident ' s location as Floor. This was written over by Staff A, the Licensed Practical Nurse (LPN) who provided nursing care for the resident on [DATE] on the 11 p.m. to 7 a.m. shift. Employee A, wrote in wheelchair over Staff B ' s entry of Floor, and initialed the change. Documentation for 1:00 a.m. indicated the resident ' s location was Floor and at 1:15 a.m., the documentation indicated the resident ' s location was Floor. Narrative Nursing notes commencing at 11:00 p.m. on [DATE] and written by Employee A, an LPN, documented: [DATE] 11:00 p.m. Resident in bed, respirations even and unlabored. No distress noted. Call light in reach. Continues on Q 15 minutes checks for safety precautions. [DATE] 11:15 p.m. Trying to get OOB (Out Of Bed) - assist up to W/C by CNA and full lap tray applied and was brought out into hallway. Resident sat in W/C with CNA on A Hall. Magazines given to her to distract her. [DATE] 11:45 p.m. Continues to sit in W/C next to CNA on A-Hall. Resident takes her Full lap tray off and puts it on Floor next to her. CNA talks to resident and asks her if she can reapply Full lap tray and she states yes. Full lap tray reapplied on W/C. Magazines given, snacks offered, toileting offered. No distress noted. [DATE] 12:15 a.m. Continues to sit in W/C next to CNA on A-Hall. Resident continues to take Full lap tray off and CNA continues to redirect and put lap tray back on and offer magazines, and snacks and conversation with resident to distract her. No distress noted. [DATE] 12:30 a.m. CNA brought resident to me near nurse ' s desk. Sitting in W/C in Front of her room. Resident put magazines in her lap and pulled lap tray off W/C and put in the Floor next to her. This nurse walked over to her and asked if I could put lap tray back on her W/C and resident states Yes. Full lap tray reapplied. Asked resident if she wanted a snack or needed to go to the bathroom and she states No. No distress noted. [DATE] 12:40 a.m. Resident continues to sit in her W/C in hallway and continues to take Full lap tray off of her W/C. This nurse continues to redirect. Asked resident if she was tired and wanted to go to bed- she states No. [DATE] 12:45 a.m. Resident continues to sit in her W/C in hallway in Front of her Room. Resident continues to take her Full lap tray off of W/C and this nurse continues to put back on with her permission. Asked resident again if she was ready for bed, she states No. I told her I needed to step next door to another patient ' s room and I would be back in a minute or two. She states Okay. [DATE] 12:50 a.m. CNA reported that resident was on the Floor. When coming out of another patients Room and into Hallway resident was lying on the Floor Across the hall from her W/C lying face down with right side of her face against the floor. Small puddle of blood noted under her head. Small laceration noted to Right temple. After looking over her body-No other injuries noted. Log rolled her over to better evaluate her, did hear her moan and respond. [DATE] 01:00 a.m. Vital Signs (VS)= ,[DATE] - 98 - 79 - 20. Neurologic check done. Alert but drowsy, PERL (Pupils Equal, React to Light), Able to move extremities, when asked if she is having pain does not answer. Laceration to Right temple cleaned with Normal Saline (NS) and patted dry, steri strips applied and dry dressing applied. Transferred from Floor to W/C with assist of 2 people plus myself. Wheeled to bed and put back to bed to continue monitoring- 1:1 supervision initiated by this nurse. CNA at bedside with resident. [DATE] 01:15 a.m. Restless in bed. VS =,[DATE] - 98 - 79 - 20. Neurologic check done. Alert, Left Pupil reactive, Right Pupil not reactive. Able to move all extremities. Dressing to Right temple dry/intact. Pupils checked by 2nd nurse - Right side not reacting. (Physician) phoned and notified of fall with laceration to Right temple and that Left pupil reacting but Right pupil non-reactive. Orders received to send out to Hospital for Evaluation and treatment. Orders written. [DATE] 01:30 a.m. Called 911 for transport to Hospital after necessary paperwork copied and prepared. [DATE] 01:35 a.m. Ambulance and Emergency Medical Technician (EMT)/Paramedics here to pick up patient. All necessary paperwork given to them. History and report given to them. [DATE] 01:40 a.m. Patient left facility via stretcher with EMT personnel with incident going to Hospital by ambulance. [DATE] 01:42 a.m. Called Hospital ER and spoke to nurse and gave her report and history on patient. [DATE] 01:45 a.m. (Family) called and notified of fall with laceration to Right temple and patient was transferred to Hospital. [DATE] 01:47 a.m. Called Risk Manager to notify of patient fall received voicemail left message. [DATE] 04:10 a.m. (Family) called this Facility to let us know patient was admitted to Hospital and she was in Intensive Care Unit (ICU) with bleed in her brain . Review of a hospital record for [DATE] revealed that Resident # 3 was transferred by Air ambulance from the first hospital to a second hospital for neurosurgical evaluation and admission for critical care. Review of the Admission History and Physical in the emergency department for the second hospital for [DATE] revealed: The patient presents with [AGE] year old Caucasian female sent here from (first hospital) for cerebral bleed, patient has a subarachnoid hemorrhage on CT done at 0300 . She fell while sitting in a wheelchair at the nursing home (NH), was a laceration to the right supraorbital area and right upper eyelid. Physical examination, on [DATE], stated Neurologic - Intubated, sedated. Impression and Plan: admitted on [DATE] post fall from chair at NH, Found to have: SAH (Subarachnoid Hemorrhage) - on [MEDICATION NAME]. The hospital record indicated the patient was admitted to the Intensive Care Unit. Review of the Discharge Summary - Death Summary , dated [DATE] revealed Hospital Course: [AGE] year old Caucasian female sent here from (name of first hospital) for cerebral bleed. The patient has a subarachnoid hemorrhage on CT done at 0300. Discussion with the patient ' s power of attorney noted that the patient is a do not resuscitate but would want surgical intervention if it could potentially help her and/or transfusion if necessary. She would not want Cardio [MEDICAL CONDITION] Resuscitation (CPR), electrical defibrillation or other resuscitative measures. The patient would want her Do Not Resuscitate (DNR) to stay in place. The patient arrived intubated and the power of attorney is aware of this. The patient is a former registered nurse with a history of dementia, incontinence of urine and has been at the nursing home about a year. She fell while sitting in a wheelchair at the nursing home. There was a laceration to the right supraorbital area and right upper eyelid. The nursing home staff had left then came back to find the patient on the ground with cut around the lateral area to the right eye. [DATE]: Sent from (first hospital) for SAH (Subarachnoid Hemorrhage) from fall out of wheelchair. CT head with contrast: several small to mod - sized foci of extra - axial hemorrhage, mainly in the sulci to frontal, parietal and temporal lobes, lacerations right supraorbital area and right upper eyelid closed in Emergency Department (ED) [DATE] Remains on mechanical vent but neuro is improving - failed SAT/SBT (Spontaneous Awakening Trial/Spontaneous Breathing Trial). [DATE] Daily SAT/SBT, patient does well on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) but not awake enough to protect airway. [DATE] Spoke with (family) and the plan is that family will most likely arrive in the next few days for eventual extubation with full DNR. If patient can awaken and protect her airway . fine, but if she cannot maintain off mechanical vent, then comfort care will be provided. [DATE] Patient becomes restless and coughs when sedation levels dropped but does not awaken/ follow commands. [DATE] No clinical change to suggest that patient can now protect airway. [DATE] On vent and not responsive and started Enteral tube feeds. [DATE] On vent and not fully alert and failed SBT. (Physician) discussed and explained to (family) about her medical problems, plan of care and prognosis. (Family) made a decision that they wanted to withdraw life support ventilator and stopped all her medications except comfort measures. She was extubated and on intravenous (IV) [MEDICATION NAME] and IV [MEDICATION NAME] and died in TICU. Family members at bedside. Preliminary cause of death listed (included but not limited to): Several small to moderate - sized foci of extra- axial hemorrhage. Hemorrhage mainly in the sulci of frontal lobes, parietal and temporal lobes. Therefore hemorrhage is likely mainly in the subarachnoid space. Most prominent foci of hemorrhage appears to be the frontal lobes and right temporal lobes after fall in nursing home from chair and she was on [MEDICATION NAME]. Acute Respiratory insufficiency, requiring mechanical ventilator and intubated on ,[DATE] and failure to wean off due to AMS (Altered Mental Status) and inability to protect airway . On [DATE] at 8:47 a.m. an interview was conducted with Staff A, the LPN who worked with Resident #3 on the 11 p.m. to 7 a.m. shift on [DATE] and wrote the nursing notes for [DATE] and [DATE]. She stated that when she came on shift for the 11:00 p.m. to 7:00 a.m. shift on [DATE]; Resident #3 was restless in the bed and not sleeping. Staff A stated they got her up in the wheelchair, put the lap tray on and brought her out in the hallway. Staff A stated she was afraid the resident would try to get up and was told not to leave her in her room alone; thus she brought her out in the hall to keep a close eye on her. Staff A stated she ' d been with someone by her side for so long. Staff A stated the resident kept taking the tray off, but never tried to get out of her chair. Staff A indicated that she and the aide would watch her and stated I had her close to the desk with me when (Staff B) went on break. Staff B brought her to me; I was doing paperwork at the desk. She stated that she had to go in to check on a resident in another room, and she parked her in front of her door, told her what I was doing and would be right back. She was parked facing the nurse ' s station at her room and I stepped into the room next door. She stated when Staff B came back to the floor after her break, she told her that Resident #3 was on the floor. Staff A stated I did not hear her get up or hear her go down. Staff A stated she had just gotten the blood pressure cuff on the other resident when she heard staff B say the resident was on the floor. She stated, her chair was by the door when I came out, she was lying diagonally in front of the wall across the hall. She stated the resident was face down with her head turned to the right and did not know how the resident got in that position. When asked if there were any other staff in the area when the resident fell she stated not that I know of. Staff A confirmed she came out to assess Resident #3 who was on the floor. She stated there was a little blood under her from the cut, superficial. She was crying a little bit. She stated that she and a Registered Nurse (RN/Staff C) checked the resident's vital signs and did neurologic checks. She stated the vital signs and neurologic checks were okay and between the two of us, felt comfortable, she only needed steri strips, no other injuries, she was crying. She stated they got her off the floor, placed her in her wheelchair and then in her bed and did neuro checks again. She stated, at that time, the neuro checks were abnormal; one pupil was not reacting, dilated and not responding . She stated she called the physician and received the order to send her to the hospital via 911. Staff A stated she had provided care for Resident #3 regularly on the 11 p.m. to 7 a.m. shifts. When asked to describe Resident # 3, she stated Some nights she was quiet and slept comfortably. Other times she was fidgety. Some nights she didn ' t sleep well, was fidgety and nervous when she was awake, we would put her in her chair, bring her out to the hall, let her socialize, give her a drink, magazines, then she would go back to sleep. An interview was held with Staff B, the CNA who provided care for Resident #3 on the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Staff B stated she had worked with Resident #3 since she came here and had provided 1:1 supervision to the resident in the past. She stated she was concerned that every 15 minute checks were not going to work for Resident #3. She stated Everyone knew it was going to be a problem. She stated, She was only every 15 minute checks, my main focus was on her. My first night having her off 1:1, I thought, this isn ' t going to work. I felt like I had to watch her every minute still. She stated she was climbing out of bed when I first came in that night. She was still the same, she had not gotten any better. When asked what the resident was like when she provided 1:1 supervision for her in the past, she stated She was restless, trying to get up, had to redirect her. Restless, tossing, turning, trying to get up, grabbing, and that she would bring her out of her room into the hall. Staff B stated when she came on shift, she does not recall if the resident was in bed. She stated when the resident was up in the hallway in her wheelchair, she stayed with her. She stated there was an activity tray on her wheelchair, she was trying to take it off, trying to get up, and she was very very busy when I was with her- I stayed with her. She stated that when she went on break, she told Staff A that she was going on break and brought Resident #3 to Staff A at the nurses ' station. She stated Q 15 minutes wasn 't going to work, that it is why when I went on break I had her covered. Staff B stated when she returned from her break, she saw Resident # 3 on the floor. She stated no one was with her and she saw no staff in the hall. Staff B stated she alerted Staff A, who was in the patient's room next door. Staff B described Resident #3 as screaming, yelling and very agitated. She stated she asked her if she was hurt, then she saw the blood. She stated she does not know where the lap tray was, thinks it was off to the side somewhere. She stated Resident #3 was in the hallway outside of her door when she found her and Staff A was taking care of another patient in another room. An interview was held on [DATE] at 10:15 am with Staff C, the RN who assisted Staff A, after Resident #3 was found on the floor. During the interview, Staff C stated she was on another hall in Station 1 at the treatment cart with her back turned to the hall Resident #3 was on. Staff C was the RN supervisor on that shift and stated she heard someone say there she goes but did not know who that was. When asked to describe Resident #3 the night prior to the fall, Staff C stated She needed to be attended to, she still needed constant supervision because of impulsiveness and lack of understanding. Staff C stated that she and Staff A initially assessed the resident's vital signs and conducted neuro checks, looked for bleeding and bruising. She stated she (Resident #3) was making a strange sound, sort of a screeching, a different sound, a screeching sound. She stated that they placed her in her wheelchair, put her in her bed and started neuro checks again. She stated we knew she needed to go out because of her behavior and her right pupil started to be non - reactive. She was responsive, crying a little bit. On [DATE] at 6: 25 p.m. an interview was

Based upon policy review, record review and interview, the facility failed to operationalize policies and procedures to prevent neglect for two of fourteen residents reviewed (#3, #4). The facility failed to ensure that all measures were taken within their control to prevent occurrences of neglect for Resident ' s # 3 and # 4. The facility chose to discontinue one to one (1:1) constant supervision around the clock for Resident #3, an [AGE] year old long term care resident with [DIAGNOSES REDACTED]. The facility chose to reduce the level of supervision from one to one to every 15 minute checks, which only required staff to observe the resident at least every fifteen minutes. The facility ' s licensed nurse neglected to increase the level of supervision to ensure Resident # 3 ' s safety, in spite of the resident ' s attempts to get out of bed on her own and her documented restlessness and impulsivity. The facility chose to leave Resident #3 unsupervised and unattended in the hallway in the middle of the night, resulting in Resident # 3 attempting to rise on her own, falling and hitting her head and sustaining a subarachnoid hemorrhage leading to her subsequent death. The facility failed to provide Resident #4 with the necessary care, support, supervision and monitoring to prevent neglect per the facility ' s abuse and neglect policy and procedures. Resident #4 was reported as actively dying, restless and anxious and dependent on staff to meet her needs. The facility ' s licensed nurses were aware of the resident ' s condition and reported that she had tried to get up on her own and was restless yet they failed to document any attempts to alleviate her symptoms and provide comfort and supervision to Resident # 4. The resident was found on the floor, alone, next to her bed, with her head on the metal frame of the over bed table surrounded by a pool of blood under her head. The resident died on the floor of her room with emergency services present. Past Non-Compliance at the Immediate Jeopardy level was identified on [DATE] as occurring on [DATE]. The Administrator was notified on [DATE] at 6:10 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings included: 1. On [DATE], the Risk Manager provided an Abuse Prevention Policy and Procedure Manual dated 2001. She stated this was the policy in place at this time. Review of the policy provided revealed: Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement: Our facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. Policy Interpretation and Implementation 1. Abuse s defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all - inclusive. Other signs and symptoms or actual abuse/neglect may not (sic) be apparent. When in doubt, report it. b. Signs of/Actual Physical Neglect: Inadequate provision of care; Caregiver indifference to resident ' s personal care and needs; Leaving someone unattended who needs supervision. Preventing Resident Abuse: Policy Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility ' s policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Policy Interpretation and Implementation: 1. The facility ' s goal is to achieve and maintain an abuse -free environment. 2. Our abuse prevention /intervention program includes, but is not necessarily limited to the following: j. Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect. k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. o. Identifying areas within the facility that may make abuse and/or neglect more likely to occur and monitoring these areas regularly. p. Striving to maintain adequate staffing on all shifts to ensure the needs of each resident are met. 3. Record review for Resident # 3 revealed that she was admitted to the facility on [DATE]. Review of the Client [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. According to www.PDR.net (Physician ' s Desk Reference) [MEDICATION NAME] is an Antiplatelet agent and side effects include increased risk of bleeding. The brand name for [MEDICATION NAME] is [MEDICATION NAME]. Review of an annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a score of 3 (indicating Severe Cognitive Impairment) on the Brief Interview for Mental Status (BIMS) assessment. The resident was coded as needing extensive assistance of two persons for bed mobility and transfer, extensive assistance of one person for ambulation and total dependence for locomotion. Balance during transition and walking was coded as not steady, only able to stabilize with human assistance and the resident utilized a wheelchair for locomotion. On [DATE] at 12:45 a.m. Resident # 3 was left alone, unsupervised, in her wheelchair in the hallway outside of her room, she was found on the floor, sustained a Subarachnoid Hemorrhage and subsequently died as a result of the fall: Narrative nursing notes, written by Employee A , an LPN, commencing on [DATE] through the early morning hours of [DATE] were as follows: [DATE] 11:00 p.m. Resident in bed, respirations even and unlabored. No distress noted. Call light in reach. Continues on Q (every) 15 minutes checks for safety precautions. [DATE] 11:15 p.m. Trying to get OOB (Out Of Bed) - assist up to wheelchair (W/C) by Certified Nursing Assistant (C.N.A.) and full lap tray applied and was brought out into hallway. Resident sat in W/C with CNA on A Hall. Magazines given to her to distract her. [DATE] 11:45 p.m. Continues to sit in W/C next to CNA on A-Hall. Resident takes her Full lap tray off and puts it on Floor next to her. CNA talks to resident and asks her if she can reapply Full lap tray and she states yes. Full lap tray reapplied on W/C. Magazines given, snacks offered, toileting offered. No distress noted. [DATE] 12:15 a.m. Continues to sit in W/C next to CNA on A-Hall. Resident continues to take Full lap tray off and CNA continues to redirect and put lap tray back on and offer magazines, and snacks and conversation with resident to distract her. No distress noted. [DATE] 12:30 a.m. CNA brought resident to me near nurse ' s desk. Sitting in W/C in Front of her room. Resident put magazines in her lap and pulled lap tray off W/C and put in the Floor next to her. This nurse walked over to her and asked if I could put lap tray back on her W/C and resident states Yes. Full lap tray reapplied. Asked resident if she wanted a snack or needed to go to the bathroom and she states No. No distress noted. [DATE] 12:40 a.m. Resident continues to sit in her W/C in hallway and continues to take Full lap tray off of her W/C. This nurse continues to redirect. Asked resident if she was tired and wanted to go to bed- she states No. [DATE] 12:45 a.m. Resident continues to sit in her W/C in hallway in Front of her Room. Resident continues to take her Full lap tray off of W/C and this nurse continues to put back on with her permission. Asked resident again if she was ready for bed, she states No. I told her I needed to step next door to another patient ' s room and I would be back in a minute or two. She states Okay. [DATE] 12:50 a.m. CNA reported that resident was on the Floor. When coming out of another patient ' s Room and into Hallway resident was lying on the Floor across the hall from her W/C lying face down with right side of her face against the floor. Small puddle of blood noted under her head. Small laceration noted to Right temple. After looking over her body-No other injuries noted. Log rolled her over to better evaluate her, did hear her moan and respond. [DATE] 01:00 a.m. Vital Signs (VS)= ,[DATE] - 98 - 79 - 20. Neurologic check done. Alert but drowsy, PERL (Pupils Equal, React to Light), Able to move extremities, when asked if she is having pain does not answer. Laceration to Right temple cleaned with Normal Saline (NS) and patted dry, steri strips applied and dry dressing applied. Transferred from Floor to W/C with assist of 2 people plus myself. Wheeled to bed and put back to bed to continue monitoring- 1:1 supervision initiated by this nurse. CNA at bedside with resident. [DATE] 01:15 a.m. Restless in bed. VS =,[DATE] - 98 - 79 - 20. Neurologic check done. Alert, Left Pupil reactive, Right Pupil not reactive. Able to move all extremities. Dressing to Right temple dry/intact. Pupils checked by 2nd nurse - Right side not reacting. (Physician) phoned and notified of fall with laceration to Right temple and that Left pupil reacting but Right pupil non-reactive. Orders received to send out to Hospital for Evaluation and treatment. Orders written. [DATE] 01:30 a.m. Called 911 for transport to Hospital after necessary paperwork copied and prepared. [DATE] 01:35 a.m. Ambulance and Emergency Medical Technician (EMT)/Paramedics here to pick up patient. All necessary paperwork given to them. History and report given to them. [DATE] 01:40 a.m. Patient left facility via stretcher with EMT personnel without incident going to Hospital by ambulance. [DATE] 01:42 a.m. Called Hospital emergency room (ER) and spoke to nurse and gave her report and history on patient. [DATE] 01:45 a.m. (Family) called and notified of fall with laceration to Right temple and patient was transferred to Hospital. [DATE] 01:47 a.m. Called Risk Manager to notify of patient fall received voicemail left message. [DATE] 04:10 a.m. (Family) called this Facility to let us know patient was admitted to Hospital and she was in Intensive Care Unit (ICU) with bleed in her brain . Review of a hospital record for [DATE] revealed that Resident # 3 was transferred by air ambulance from the first hospital to a second hospital for neurosurgical evaluation and admission for critical care. Review of the Admission History and Physical in the emergency department for the second hospital for [DATE] revealed: The patient presents as an [AGE] year old Caucasian female sent here from (first hospital) for cerebral bleed. Patient has a subarachnoid hemorrhage on CT done at 0300 . She fell while sitting in a wheelchair at the nursing home (NH), has a laceration to the right supraorbital area and right upper eyelid. Physical examination, on [DATE], stated Neurologic - Intubated, sedated. Impression and Plan: admitted on [DATE] post fall from chair at NH, Found to have: SAH (Subarachnoid Hemorrhage) - on [MEDICATION NAME]. The hospital record indicated the patient was admitted to the Intensive Care Unit. Review of the Discharge Summary - Death Summary, dated [DATE] revealed Hospital Course: [AGE] year old Caucasian female sent here from (name of first hospital) for cerebral bleed. The patient has a subarachnoid hemorrhage on CT done at 0300. Discussion with the patient ' s power of attorney noted that the patient is a do not resuscitate but would want surgical intervention if it could potentially help her and/or transfusion if necessary. She would not want Cardio [MEDICAL CONDITION] Resuscitation (CPR), electrical defibrillation or other resuscitative measures. The patient would want her Do Not Resuscitate (DNR) to stay in place. The patient arrived intubated and the power of attorney is aware of this. The patient is a former registered nurse with a history of dementia, incontinence of urine and has been at the nursing home about a year. She fell while sitting in a wheelchair at the nursing home. There was a laceration to the right supraorbital area and right upper eyelid. The nursing home staff had left then came back to find the patient on the ground with cut around the lateral area to the right eye. [DATE]: Sent from (first hospital) for SAH (Subarachnoid Hemorrhage) from fall out of wheelchair. CT head with contrast: several small to mod - sized foci of extra - axial hemorrhage, mainly in the sulci to frontal, parietal and temporal lobes, lacerations right supraorbital area and right upper eyelid closed in Emergency Department (ED) [DATE] Remains on mechanical vent but neuro is improving - failed SAT/SBT (Spontaneous Awakening Trial/Spontaneous Breathing Trial). [DATE] Daily SAT/SBT, patient does well on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) but not awake enough to protect airway. [DATE] Spoke with (family) and the plan is that family will most likely arrive in the next few days for eventual extubation with full DNR. If patient can awaken and protect her airway . fine, but if she cannot maintain off mechanical vent, then comfort care will be provided. [DATE] Patient becomes restless and coughs when sedation levels dropped but does not awaken/ follow commands. [DATE] No clinical change to suggest that patient can now protect airway. [DATE] On vent and not responsive and started Enteral tube feeds. [DATE] On vent and not fully alert and failed SBT. (Physician) discussed and explained to (family) about her medical problems, plan of care and prognosis. (Family) made a decision that they wanted to withdraw life support ventilator and stopped all her medications except comfort measures. She was extubated and on intravenous (IV) [MEDICATION NAME] and IV [MEDICATION NAME] and died in TICU. Family members at bedside. Preliminary cause of death listed (included but not limited to): Several small to moderate - sized foci of extra- axial hemorrhage. Hemorrhage mainly in the sulci of frontal lobes, parietal and temporal lobes. Therefore hemorrhage is likely mainly in the subarachnoid space. Most prominent foci of hemorrhage appears to be the frontal lobes and right temporal lobes after fall in nursing home from chair and she was on [MEDICATION NAME]. Acute Respiratory insufficiency, requiring mechanical ventilator and intubated on ,[DATE] and failure to wean off due to AMS (Altered Mental Status) and inability to protect airway . A phone interview was conducted with a family member of Resident #3, on [DATE] at 10:55 a.m. She stated that her family member, Resident #3, had been on 1: 1 supervision since the beginning of her stay and was on it up until the day she fell . She stated the Risk Manager called her on [DATE] about decreasing the 1:1 supervision to every 15 minute checks. The Risk Manager told the family member that she had done time studies and evaluations and observed the resident for a half an hour. She stated she told the risk manager she didn ' t like it but she couldn ' t stop her from doing it and that it was basically a done deal when she called me. She stated she asked the risk manager, do you really have to do this? and the Risk Manager responded to her, It ' s time to do it. She stated she was told the observation of Resident #3 was for 30 minutes while Resident #3 was at the nurse ' s station. She stated that if the observation had been made when Resident #3 was left alone and if it had been extended 12- 13 hours, they probably would have made a different decision because she was getting up. The family member stated that the Risk Manager called her again that day to tell her that there was now a lap tray. She stated, she knew I was concerned, I was worried like crazy. She stated that the next call she received was around 1 ish, the next morning ([DATE]) and it was the nurse telling her that Resident #3 was up late, restless, trying to get out of bed and that she put her in her wheelchair with the lap tray on her and put her in the hallway. She stated the nurse told her she went into another resident ' s room, heard noise in the hallway and found Resident #3 out of her wheelchair on the floor, across the hall and that she had reinstituted 1:1 care. The family member stated that the description given to her of Resident #3 ' s behavior that night flew in the face of the lack of impulsiveness that the Risk Manager observed earlier in the day. The family member stated that Resident #3 had suffered a subarachnoid hemorrhage due to the fall and the physician didn ' t think she would make it as she was not responding and could not protect her airway. She stated she and other family members wanted to give the resident every opportunity to recover but she progressively didn ' t come out of it and there was so much brain damage from the hemorrhage. She stated, it was horrible, she was such a sweet lady, she was going through hell, she wouldn ' t have wanted this and she and other family members made the decision to take her off the ventilator. She stated She didn ' t make it. The family member stated 1:1 saved her life for as long as they did it. It was such a shock, she had other comorbid conditions but we weren ' t expecting this. The decision to take her off the one to one care and the lack of common sense when she tried to get out of bed and wouldn ' t keep the lap tray on was a formula for disaster, it didn ' t need to happen, and it shortened her life. Record review revealed that Resident #3 sustained two falls in early 2015: on [DATE] and [DATE]. The resident was placed on one to one supervision in [DATE] and remained on one to one supervision from [DATE] until approximately 10:00 a.m. on [DATE]. The resident sustained [REDACTED]. Review of a Summary of Plan of Care, completed by a registered nurse on [DATE], 4 days prior to the resident ' s fall, revealed: Provide ½ side rails x 2 as enabler, geo mattress, w/c cushion, off load heels when in bed, provide 1: 1 increased observation 7 days/ week by facility staff due to impulsiveness /[MEDICAL CONDITION].Speech is clear but she appears confused and does not answer my questions appropriately . Requires 1: 1 supervision ,[DATE] due to impulsiveness and poor safety awareness. The Narrative summary includes Transfers with 1 person assist. Uses the w/c for mobility and it is propelled by staff. Review of Care plans for Resident #3 revealed a care plan, dated [DATE] and last reviewed [DATE] for a problem of risk for falls/injuries related to: [MEDICAL CONDITION], Decreased Activities of Daily Living (ADL ' s), Impaired Hearing, Impaired Memory, Impaired Vision, Unsteady Gait, and history of falls. Goals were listed as Will have as close to no falls possible by managing risk factors, if fall occurs, will have minimal injuries related to falls through next review. Fall risk Score 90 = High risk. Interventions included : Remind not to stand without assistance or use of assistive device if utilized; Use gait belt when helping to ambulate/transfer; Instruct/reinforce safety measures with ( resident )/ family such as transfer techniques, proper foot wear, locking wheelchair; Keep call light within reach; Encourage to ask for assistance as needed; Falling precautions program: if fall score is 25 or higher will use yellow wrist band; Monitor for changes in ADL ' s Cognition, Behavior, Mood and Medications for Potential Risk Factors; Staff will be responsive to individual hearing, vision or communication concerns (keep room and hallways free from hazardous objects/clutter, adequate lighting, reduction of background noise); Keep bed in lowest position to the floor when care is not being rendered and lock bed wheels at all times. A new care plan was written [DATE], when the resident was changed from 1: 1 supervision to every 15 minute checks, which listed a problem of Is in need of Q (every) 15 minute checks around the clock. Staff to resident assignment for closer supervision, monitoring and/or observation reference to but not limited to: impulsiveness at times. The goal was Will have no adverse outcomes/injuries through next review date. The interventions were not revised to reflect the change of level of supervision from 1:1 to Q 15 minute checks. Interventions still included The staff member assigned to the q 15 minutes around the clock checks will accompany the resident at all times (including bathing, showers, meals, toileting and off - unit activities). Resident will be within arm ' s reach at all times, even while sleeping; The staff member assigned to Q 15 minutes checks around the clock will not leave the resident at any time without a replacement staff member in place (breaks, meals, restroom, change of shift). The resident will not be left alone at any times; Staff member performing Q 15 minute around the clock will report to nurse any behaviors or changes in condition immediately; Try alternative measures to encourage relaxation and or provide distraction. In the assessment section of Resident # 3 ' s record was a form, dated [DATE] (one week prior to the resident ' s fall), entitled Evaluation of Need for Specialized Supervision, Observation and/or Monitoring, completed by the Risk Manager. Review of the form revealed yes responses were checked for the resident in reference to Is the resident non- adherent to safety interventions? and Does the resident have any other socially inappropriate behavior that poses a risk to self or others (i.e. public disrobing, rummaging in other ' s belongings, etc.?) A narrative comment revealed Resident who has extreme impulsivity will stand unassisted and attempt to walk & falls. She is unable to be left unattended so she is currently on 1: 1. Summary of findings and recommendations revealed Continue 1: 1 supervision and there were checkmarks for 1: 1 Nursing Staff Supervision Around the Clock. Review of the record revealed that Resident # 3 remained on 1: 1 supervision after this assessment until another assessment was completed seven days later. Review of an Evaluation of Need for Specialized Supervision, Observation and/or Monitoring dated [DATE] revealed a yes response for the question Is the resident non - adherent to safety interventions? Review of the narrative comments revealed Resident currently on 1: 1 supervision. She has had minimal needs of redirection as per 1: 1 supervision monitoring sheets. Evaluation conducted on [DATE] from 9: 30 -10: 00, Zero impulsive movements noted at this time. Will call MD (Medical Doctor) and suggest Q 15 minutes check around the clock to see if we can reduce the 1:1. Tools used: Observation sheets over 2 months, staff interviews, current assessment. Summary of Findings and Recommendations revealed Resident noted during a 30 minute observation period to have zero impulsive moments. 11 to 7 staff reporting zero attempts to rise at night and per 1:1 observation sheets she has moments of needed redirection that are successful. Will attempt reduction of 1:1 to Q 15 minute checks if MD agrees. Date physician notified: [DATE]. Physician orders [REDACTED]. Start Q 15 minute checks around the clock and may not be in room alone while up in wheelchair. Review of Nurse ' s notes in the resident ' s chart revealed an entry signed by the Risk Manager, for [DATE] at 10:00 a.m., which stated, Resident observed for possibility of decrease from 1:1 to Q 15 minute checks. Per log book, has minimum episodes of impulsivity and when she does redirection is + (positive). Resident sitting at nurses station up in wheelchair sitting well speaking with staff and residents that pass by. Zero moments of impulsivity. Spoke with POA (Power of Attorney) who agrees with reduction to Q 15 minute checks, MD agreed as well. Order noted to D/C 1:1, Start Q 15 minute checks ATC (around the clock). Possible for activity tray as resident likes books and magazines and a lap tray would facilitate this. Will Monitor. A second Nurse ' s note, written by the Risk Manager and dated [DATE] at 2:00 p.m. revealed, Full lap activity tray added to promote independent activities while up in wheelchair, MD and family aware. A Physical Restraint Elimination Assessment form was completed by the Risk Manager on [DATE]. Instructions on the form indicate Restrained individuals should be reviewed AT LEAST QUARTERLY to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or a total restraint elimination. For each category listed below, assess the resident by circling the corresponding score that best describe his/ her current status in the appropriate assessment column. Add the column of numbers to obtain the score. Review of the responses on the form revealed that responses were circled for: Ambulation - Ambulates with assist of two, Weight Bearing - full weight bearing, Sitting balance - leans to a side, forward, backward and slides down. ADLS - Requires total assist of two Physical Limitations - History of falls Vision status - adequate with glasses/without glasses Orientation - Disoriented (x 2 spheres) Comprehension - Directions must be frequently repeated Behavior/ Mood - Exhibits / Expresses fears or anxieties Activity Participation - Participates with assistance Medication Therapy - Not taking any chemical restraint. The total score was recorded as 18 and the scoring directions indicated a score of 0 - 20 was a Priority Candidate. Review of the assessment revealed: 1. Candidate Status as determined by Total Score on reverse - checked as Priority. 2. Candidate for restraint reduction or elimination program - choice of yes or no check box, no response was documented If yes, Date program to start: [DATE] Action Plan: Not a Restraint. 3. Additional Comments: This is an Activity tray that resident can remove. Review of physician telephone orders for [DATE] revealed an order with no time noted for 1. D/C all orders r/t 1: 1 Supervision. 2. Start Q 15 minute checks ATC. (Around the Clock) A second order with no time noted, also dated [DATE], stated Resident may have an Activity Full Lap tray to promote independence with activities. Check Q 30 minutes and remove Q 2 hours and PRN (as needed) for Group Activities, Meals, ADLS and Toileting. Review of documentation for Q 15 minute checks for Resident #3 for [DATE] revealed that from 9:30 a.m. to 8 p.m., the resident was noted to be at the Station 1 Nursing Station the majority of the time. At 8: 15 p.m., she was noted to be in the bathroom and from 8:30 p.m. to 11 p.m., she was documented as being in bed. Documentation commencing from 11:15 p.m. to 11:30 p.m. revealed the resident ' s location was noted to be up in wheelchair (W/C). From 11:45 p.m. on [DATE] to 12:30 a.m. on [DATE], the resident ' s location was documented as W/C A Hall. At 12:45 a.m., Staff B, the Certified Nursing Assistant (C.N.A.) who provided care for this resident during the 11 p.m. to 7 a.m. shift on [DATE], had documented the resident ' s location as Floor. This was written over by Staff A, the Licensed Practical Nurse (LPN) who provided nursing care for the resident on [DATE] on the 11 p.m. to 7 a.m. shift. Employee A, wrote in wheelchair over Staff B's entry of Floor, and initialed the change. Documentation for 1:00 a.m. indicated the resident ' s location was Floor and at 1:15 a.m., the documentation indicated the resident ' s location was Floor. An interview was conducted with the Risk Manager, on [DATE] at 1:32 p.m. regarding reducing the level of supervision for Resident # 3 from 1: 1 supervision to every 15 minute checks on [DATE]. She stated She was 18 months on 1:1, we would review her regularly and she started showing improvement at the end. She stated she looked at the 1:1 log sheets, looked at the resident. She stated the day I assessed her was following no behavior for several days. The Risk Manager stated she reviewed documentation back to [DATE] and there had been no incidents and no attempts to get up. She stated she spoke with the resident ' s daughter, told her she had noticed an improvement and the daughter told her let's try this. She stated that she assured the daughter she wouldn ' t hesitate to put her back on 1:1 if she needed it. She stated she discussed it with Resident #3's physician and he agreed and gave the order to discontinue to 1:1 supervision and start every 15 minute checks. The Risk Manager stated she noticed that the resident wanted a book or a magazine in her hands and sat in her wheelchair with her legs crossed. And she got her an activity tray that she could take on and off. The Risk Manager was asked why when she completed the assessment Evaluation of Need for Specialized Supervision, Observation and/or Monitoring on [DATE], seven days prior, did she document the need to continue 1:1 supervision due to the resident's extreme impulsivity and attempts to stand unassisted. She stated that was her quarterly review and she decided to keep her on 1:1 because she was going for surgery. She stated she left her on 1:1 with a plan to reevaluate her when she came back to make sure pain was not going to be an issue. Review of Resident #3's record revealed that she went to the hospital for a procedure on [DATE] and returned to the facility on [DATE] after an overnight stay in the hospital. The Risk Manager stated she conducted an investigation regarding the fall sustained by Resident #3 on [DATE]. She stated That evening she was restless in her bed, they got her up, sat her in her chair, put the activity tray on her and put her at the nurse's station. The nurse would talk to her, had CNA sit next to her and give her different magazines. She stated she was taking off the tray, it wasn ' t a restraint. She stated that it was time for the CNA to go on break; the CNA took her to the nurse and the nurse at the nurse's station was talking to the resident over the counter. She stated a call light went off, the nurse put the tray back on and gave her a magazine and went in to the other resident ' s room to assist. She stated the nurse heard a commotion in the hallway, stepped out of the room and Resident #3 had fallen. The Risk Manager stated that the wheelchair was right where the nurse left it, it appeared she had taken two to three steps and had fallen. She was more diagonal, kitty cornered across the hall, facing the nurses station. She stated that it was pure speculation that she may have stood up and took a couple of steps. The Risk Manager stated that Resident #3 had been off of 1:1 supervision for less than 24 hours and she felt it would have been beneficial for the nurse to have increased the level of supervision back to 1:1 when Resident #3 showed signs of restlessness by climbing out of bed and repeatedly taking the lap tray off. She stated this would have possibly prevented the fall. On [DATE] at 8:47 a.m. an interview was conducted with Staff A, the LPN who worked with Resident #3 on the 11 p.m. to 7 a.m. shift on [DATE] and wrote the nursing notes for [DATE] and [DATE]. She stated t

Based on record review, interview, and policy review, the facility failed to provide the supervision, monitoring and support services needed to prevent serious falls for two (#3, #4) of fourteen residents reviewed for accidents and supervision. Resident #3 sustained a fall that resulted in subsequent death due to the injury associated with the fall. Resident #4, a frail, vulnerable resident who was reported to be actively dying and experiencing terminal restlessness and anxiety, sustained an unsupervised fall with injury and subsequent death within approximately 30 minutes of the fall. Resident # 3 was an [AGE] year-old long term care resident with [DIAGNOSES REDACTED]. She required extensive assistance of two persons for transfers and extensive assistance to ambulate. The facility chose to reduce the resident ' s level of supervision to 15 minute checks from the prior level of one to one (1:1) 24 hour/7 day a week visual supervision. The resident fell sustaining a subarachnoid hemorrhage within 12. 5 hours of the one to one supervision being discontinued. Despite the resident ' s attempt to get out of bed on her own and documented periods of restlessness and impulsivity, the facility ' s licensed nurse failed to increase the level of supervision to ensure the resident ' s safety and well-being. Resident #3 was left alone in the hallway where she attempted to rise, and fell , hitting her head, and sustaining a subarachnoid hemorrhage with subsequent death Resident # 4 was a terminally ill resident in the process of actively dying. Staff reported that the resident was restless, uncomfortable, anxious and attempting to rise. Despite awareness of the resident ' s condition by facility staff, the resident was left unsupervised alone in her room with no documentation of increased supervision, monitoring or support. The resident was subsequently found on the floor of her room in a puddle of blood. The resident died on the floor of her room with emergency services present. The facility's failure to provide the level of oversight necessary to ensure the safety of residents resulted in Past Non-Compliance at the Immediate Jeopardy level, identified on [DATE], as occurring on [DATE]. The Administrator was notified on [DATE] at 6:10 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings Included: 1. Review of the record for Resident # 3 revealed the following Narrative Nursing notes commencing at 11:00 p.m. on [DATE] and written by Employee A, an LPN: [DATE] 11:00 p.m. Resident in bed, respirations even and unlabored. No distress noted. Call light in reach. Continues on Q (every) 15 minutes checks for safety precautions. [DATE] 11:15 p.m. Trying to get OOB (Out Of Bed) - assist up to W/C (wheelchair) by Certified Nursing Assistant (C.N.A.) and full lap tray applied and was brought out into hallway. Resident sat in W/C with CNA on A Hall. Magazines given to her to distract her. [DATE] 11:45 p.m. Continues to sit in W/C next to CNA on A-Hall. Resident takes her Full lap tray off and puts it on Floor next to her. CNA talks to resident and asks her if she can reapply Full lap tray and she states yes. Full lap tray reapplied on W/C. Magazines given, snacks offered, toileting offered. No distress noted. [DATE] 12:15 a.m. Continues to sit in W/C next to CNA on A-Hall. Resident continues to take Full lap tray off and CNA continues to redirect and put lap tray back on and offer magazines, and snacks and conversation with resident to distract her. No distress noted. [DATE] 12:30 a.m. CNA brought resident to me near nurse's desk. Sitting in W/C in Front of her room. Resident put magazines in her lap and pulled lap tray off W/C and put on the Floor next to her. This nurse walked over to her and asked if I could put lap tray back on her W/C and resident states Yes. Full lap tray reapplied. Asked resident if she wanted a snack or needed to go to the bathroom and she states No. No distress noted. [DATE] 12:40 a.m. Resident continues to sit in her W/C in hallway and continues to take Full lap tray off of her W/C. This nurse continues to redirect. Asked resident if she was tired and wanted to go to bed- she states No. [DATE] 12:45 a.m. Resident continues to sit in her W/C in hallway in Front of her Room. Resident continues to take her Full lap tray off of W/C and this nurse continues to put back on with her permission. Asked resident again if she was ready for bed, she states No. I told her I needed to step next door to another patient's room and I would be back in a minute or two. She states Okay. [DATE] 12:50 a.m. CNA reported that resident was on the Floor. When coming out of another patients Room and into Hallway resident was laying in the Floor Across the hall from her W/C lying face down with right side of her face against the floor. Small puddle of blood noted under her head. Small laceration noted to Right temple. After looking over her body-No other injuries noted. Log rolled her over to better evaluate her, did hear her moan and respond. [DATE] 01:00 a.m. Vital Signs (VS)= ,[DATE] - 98 - 79 - 20. Neurologic check done. Alert but drowsy, PERL (Pupils Equal, React to Light), Able to move extremities, when asked if she is having pain does not answer. Laceration to Right temple cleaned with Normal Saline (NS) and patted dry, steri strips applied and dry dressing applied. Transferred from Floor to W/C with assist of 2 people plus myself. Wheeled to bed and put back to bed to continue monitoring- 1:1 supervision initiated by this nurse. CNA at bedside with resident. [DATE] 01:15 a.m. Restless in bed. VS =,[DATE] - 98 - 79 - 20. Neurologic check done. Alert, Left Pupil reactive, Right Pupil not reactive. Able to move all extremities. Dressing to Right temple dry/intact. Pupils checked by 2nd nurse - Right side not reacting. (Physician) phoned and notified of fall with laceration to Right temple and that Left pupil reacting but Right pupil non-reactive. Orders received to send out to Hospital for Evaluation and treatment. Orders written. [DATE] 01:30 a.m. Called 911 for transport to Hospital after necessary paperwork copied and prepared. [DATE] 01:35 a.m. Ambulance and Emergency Medical Technician (EMT)/Paramedics here to pick up patient. All necessary paperwork given to them. History and report given to them. [DATE] 01:40 a.m. Patient left facility via stretcher with EMT personnel without incident going to Hospital by ambulance. [DATE] 01:42 a.m. Called Hospital emergency room (ER) and spoke to nurse and gave her report and history on patient. [DATE] 01:45 a.m. (Family) called and notified of fall with laceration to Right temple and patient was transferred to Hospital. [DATE] 01:47 a.m. Called Risk Manager to notify of patient fall received voicemail left message. [DATE] 04:10 a.m. (Family) called this Facility to let us know patient was admitted to Hospital and she was in Intensive Care Unit (ICU) with bleed in her brain. Review of a hospital record for [DATE] revealed that Resident # 3 was transferred by Air ambulance from the first hospital to a second hospital for neurosurgical evaluation and admission for critical care. Review of the Admission History and Physical in the emergency department for the second hospital for [DATE] revealed: The patient, an [AGE] year old Caucasian female, was sent here from (first hospital) for cerebral bleed. Patient has a subarachnoid hemorrhage on CT done at 0300 . She fell while sitting in a wheelchair at the nursing home (NH) with a laceration to the right supraorbital area and right upper eyelid. Physical examination, on [DATE], stated Neurologic - Intubated, sedated. Impression and Plan: admitted on [DATE] post fall from chair at NH, Found to have: SAH (Subarachnoid Hemorrhage) - on Plavix. The hospital record indicated the patient was admitted to the Intensive Care Unit. Review of the Discharge Summary - Death Summary, dated [DATE] revealed Hospital Course: [AGE] year old Caucasian female sent here from (name of first hospital) for cerebral bleed. The patient has a subarachnoid hemorrhage on CT done at 0300. Discussion with the patient's power of attorney noted that the patient is a do not resuscitate but would want surgical intervention if it could potentially help her and/or transfusion if necessary. She would not want Cardio Pulmonary Resuscitation (CPR), electrical defibrillation or other resuscitative measures. The patient would want her Do Not Resuscitate (DNR) to stay in place. The patient arrived intubated and the power of attorney is aware of this. The patient is a former registered nurse with a history of dementia, incontinence of urine and has been at the nursing home about a year. She fell while sitting in a wheelchair at the nursing home. There was a laceration to the right supraorbital area and right upper eyelid. The nursing home staff had left then came back to find the patient on the ground with cut around the lateral area to the right eye. [DATE]: Sent from (first hospital) for SAH (Subarachnoid Hemorrhage) from fall out of wheelchair. CT head with contrast: several small to mod - sized foci of extra - axial hemorrhage, mainly in the sulci to frontal, parietal and temporal lobes, lacerations right supraorbital area and right upper eyelid closed in Emergency Department (ED). [DATE] Remains on mechanical vent but neuro is improving - failed SAT/SBT (Spontaneous Awakening Trial/Spontaneous Breathing Trial). [DATE] Daily SAT/SBT, patient does well on CPAP (Continuous Positive Airway Pressure) but not awake enough to protect airway. [DATE] Spoke with (family) and the plan is that family will most likely arrive in the next few days for eventual extubation with full DNR. If patient can awaken and protect her airway . fine, but if she cannot maintain off mechanical vent, then comfort care will be provided. [DATE] Patient becomes restless and coughs when sedation levels dropped but does not awaken/ follow commands. [DATE] No clinical change to suggest that patient can now protect airway. [DATE] On vent and not responsive and started Enteral tube feeds. [DATE] On vent and not fully alert and failed SBT. (Physician) discussed and explained to (family) about her medical problems, plan of care and prognosis. (Family) made a decision that they wanted to withdraw life support ventilator and stopped all her medications except comfort measures. She was extubated and on intravenous (IV) Morphine and IV Ativan and died in TICU. Family members at bedside. Preliminary cause of death listed (included but not limited to): Several small to moderate - sized foci of extra- axial hemorrhage. Hemorrhage mainly in the sulci of frontal lobes, parietal and temporal lobes. Therefore, hemorrhage is likely mainly in the subarachnoid space. Most prominent foci of hemorrhage appears to be the frontal lobes and right temporal lobes after fall in nursing home from chair and she was on Plavix. Acute Respiratory insufficiency, requiring mechanical ventilator and intubated on ,[DATE] and failure to wean off due to AMS (Altered Mental Status) and inability to protect airway . On [DATE] at 8:47 a.m. an interview was conducted with Staff A, the LPN who worked with Resident #3 on the 11 p.m. to 7 a.m. shift on [DATE] and wrote the nursing notes for [DATE] and [DATE]. She stated that when she came on shift for the 11:00 p.m. to 7:00 a.m. shift on [DATE]; Resident #3 was restless in the bed and not sleeping. Staff A stated they got her up in the wheelchair, put the lap tray on and brought her out in the hallway. Staff A stated she was afraid the resident would try to get up and was told not to leave her in her room alone; thus she brought her out in the hall to keep a close eye on her. Staff A stated she'd been with someone by her side for so long. Staff A stated the resident kept taking the tray off, but never tried to get out of her chair. Staff A indicated that she and the aide would watch her and stated I had her close to the desk with me when (Staff B) went on break. Staff B brought her to me; I was doing paperwork at the desk. She stated that she had to go in to check on a resident in another room, and she parked her in front of her door, told her what I was doing and would be right back. She was parked facing the nurse's station at her room and I stepped into the room next door. She stated when Staff B came back to the floor after her break, she told her that Resident #3 was on the floor. Staff A stated I did not hear her get up or hear her go down. Staff A stated she had just gotten the blood pressure cuff on the other resident when she heard Staff B say the resident was on the floor. She stated, Her chair was by the door when I came out, she was lying diagonally in front of the wall across the hall. She stated the resident was face down with her head turned to the right and did not know how the resident got in that position. When asked if there were any other staff in the area when the resident fell she stated not that I know of. Staff A confirmed she came out to assess Resident #3 who was on the floor. She stated there was a little blood under her from the cut, superficial. She was crying a little bit. She stated that she and a Registered Nurse (RN/Staff C) checked the resident's vital signs and did neurologic checks. She stated the vital signs and neurologic checks were okay and between the two of us, felt comfortable, she only needed steri strips, no other injuries, she was crying. She stated they got her off the floor, placed her in her wheelchair and then in her bed and did neuro checks again. She stated, at that time, the neuro checks were abnormal; one pupil was not reacting, dilated and not responding. She stated she called the physician and received the order to send her to the hospital via 911. Staff A stated she had provided care for Resident #3 regularly on the 11 p.m. to 7 a.m. shifts. When asked to describe Resident # 3, she stated Some nights she was quiet and slept comfortably. Other times she was fidgety. Some nights she didn't sleep well, was fidgety and nervous when she was awake, we would put her in her chair, bring her out to the hall, let her socialize, give her a drink, magazines, then she would go back to sleep. An interview was held with Staff B, the CNA who provided care for Resident #3 on the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Staff B stated she had worked with Resident #3 since she came here and had provided 1:1 supervision to the resident in the past. She stated she was concerned that every 15 minute checks were not going to work for Resident #3. She stated Everyone knew it was going to be a problem. She stated, She was only every 15 minute checks, my main focus was on her. My first night having her off 1:1, I thought, this isn ' t going to work. I felt like I had to watch her every minute still. She stated she was climbing out of bed when I first came in that night. She was still the same, she had not gotten any better. When asked what the resident was like when she provided 1:1 supervision for her in the past, she stated She was restless, trying to get up, had to redirect her. Restless, tossing, turning, trying to get up, grabbing, and that she would bring her out of her room into the hall. Staff B stated when she came on shift, she does not recall if the resident was in bed. She stated when the resident was up in the hallway in her wheelchair, she stayed with her. She stated there was an activity tray on her wheelchair, she was trying to take it off, trying to get up, and she was very, very busy when I was with her- I stayed with her. She stated that when she went on break, she told Staff A that she was going on break and brought Resident #3 to Staff A at the nurses' station. She stated Q 15 minutes wasn't going to work, that it is why when I went on break I had her covered. Staff B stated when she returned from her break, she saw Resident # 3 on the floor. She stated no one was with her and she saw no staff in the hall. Staff B stated she alerted Staff A, who was in the patient ' s room next door. Staff B described Resident #3 as screaming, yelling and very agitated. She stated she asked her if she was hurt, then she saw the blood. She stated she does not know where the lap tray was, thinks it was off to the side somewhere. She stated Resident #3 was in the hallway outside of her door when she found her and Staff A was taking care of another patient in another room. An interview was held on [DATE] at 10:15 am with Staff C, the RN who assisted Staff A, after Resident #3 was found on the floor. During the interview, Staff C stated she was on another hall in Station 1 at the treatment cart with her back turned to the hall Resident #3 was on. Staff C was the RN supervisor on that shift and stated she heard someone say there she goes but did not know who that was. When asked to describe Resident #3 the night prior to the fall, Staff C stated She needed to be attended to, she still needed constant supervision because of impulsiveness and lack of understanding. Staff C stated that she and Staff A initially assessed the resident's vital signs and conducted neuro checks, looked for bleeding and bruising. She stated she (Resident #3) was making a strange sound, sort of a screeching, a different sound, a screeching sound. She stated that they placed her in her wheelchair, put her in her bed and started neuro checks again. She stated we knew she needed to go out because of her behavior and her right pupil started to be non - reactive. She was responsive, crying a little bit. On [DATE] at 6: 25 p.m. an interview was held with Staff D, an LPN who stated she provided care routinely for Resident #3 on the 3 p.m. to 11 p.m. shift. Staff D stated she was not working the day that Resident #3 fell . She stated, They had put her on 1: 1 for a long time, she was under our close watch and She tried to get up, that is why we kept a watch on her. Staff D stated, In the days before she fell , she was still trying to get up, so we had to watch her close. On [DATE] at 9:55 a.m. an interview was conducted with Staff E, a CNA who stated she had provided 1:1 supervision for Resident #3. Staff E described Resident #3 as In the beginning she was very restless, trying to jump up and we would have to redirect her. She would hear something in the hall, wanted to bake a cake. Toward the end, it wasn't as much but once in a while she would try and get up from her chair. A phone interview was conducted with Resident #3's physician on [DATE] at approximately 8:20 a.m. The physician stated that the facility usually lets him know when they are going to increase or decrease the level of supervision for a resident, but he could not recall if he was informed of decreased supervision for Resident #3 and stated it was a long time ago. The physician stated Resident #3 was on 1:1 for almost the majority of the time since her admission to the facility, behavior had improved, and she no longer needed that particular supervision. He stated the family was notified of the change in the supervision. The physician stated the resident was able to be by herself without someone right with her, but unfortunately she fell . Review of documentation for Q 15 minute checks for Resident #3 for [DATE] revealed that from 9:30 a.m. to 8 p.m., the resident was noted to be at the Station 1 Nursing Station the majority of the time. At 8: 15 p.m., she was noted to be in the bathroom and from 8:30 p.m. to 11 p.m., she was documented as being in bed. Documentation commencing from 11:15 p.m. to 11:30 p.m. revealed the resident's location was noted to be up in wheelchair (W/C). From 11:45 p.m. on [DATE] to 12:30 a.m. on [DATE], the resident's location was documented as W/C A Hall. At 12:45 a.m., Staff B, the Certified Nursing Assistant (C.N.A.) who provided care for this resident during the 11 p.m. to 7 a.m. shift on [DATE], had documented the resident's location as Floor. This was written over by Staff A, the Licensed Practical Nurse (LPN) who provided nursing care for the resident on [DATE] on the 11 p.m. to 7 a.m. shift. Employee A, wrote in wheelchair over Staff B's entry of Floor, and initialed the change. Documentation for 1:00 a.m. indicated the resident's location was Floor and at 1:15 a.m., the documentation indicated the resident's location was Floor. Record review for Resident # 3 revealed that she was admitted to the facility on [DATE]. Review of the Client [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. According to www.PDR.net (Physician's Desk Reference) Clopidogrel is an Antiplatelet agent with side effects to include increased risk of bleeding. The brand name for Clopidogrel is Plavix. Record review revealed Resident #3 sustained two falls in early 2015, [DATE] and [DATE]. The resident was placed on one to one supervision in [DATE] and remained on one to one supervision from [DATE] until approximately 10:00 a.m. on [DATE]. The resident had sustained no falls for a period of over 13 months while she received 1:1 supervision. Review of an annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a score of 3 (indicating Severe Cognitive Impairment) on the Brief Interview for Mental Status (BIMS) assessment. The resident was coded as needing extensive assistance of two persons for bed mobility and transfer, extensive assistance of one person for ambulation and total dependence for locomotion. Balance during transition and walking was coded as not steady, only able to stabilize with human assistance and the resident utilized a wheelchair for locomotion. Review of a Summary of Plan of Care, completed by a registered nurse on [DATE] revealed: Provide ½ side rails x 2 as enabler, geo mattress, w/c cushion, off load heels when in bed, provide 1: 1 increased observation 7 days/ week by facility staff due to impulsiveness / CVA .Speech is clear but she appears confused and does not answer my questions appropriately . Requires 1: 1 supervision ,[DATE] due to impulsiveness and poor safety awareness. The Narrative summary includes Transfers with 1 person assist. Uses the w/c for mobility and it is propelled by staff. Review of Care plans for Resident #3 revealed a care plan, dated [DATE] and last reviewed [DATE] for a problem of risk for falls/injuries related to: CVA, Decreased Activities of Daily Living (ADL's), Impaired Hearing, Impaired Memory, Impaired Vision, Unsteady Gait, and history of falls. Goals were listed as Will have as close to no falls possible by managing risk factors, if fall occurs, will have minimal injuries related to falls through next review. Fall risk Score 90 = High risk. Interventions included : Remind not to stand without assistance or use of assistive device if utilized; Use gait belt when helping to ambulate/transfer; Instruct/reinforce safety measures with ( resident )/ family such as transfer techniques, proper foot wear, locking wheelchair; Keep call light within reach; Encourage to ask for assistance as needed; Falling precautions program: if fall score is 25 or higher will use yellow wrist band; Monitor for changes in ADL's Cognition, Behavior, Mood and Medications for Potential Risk Factors; Staff will be responsive to individual hearing, vision or communication concerns (keep room and hallways free from hazardous objects/clutter, adequate lighting, reduction of background noise); Keep bed in lowest position to the floor when care is not being rendered and lock bed wheels at all times. A new care plan was written [DATE], when the resident was changed from 1: 1 supervision to every 15 minute checks, which listed a problem of Is in need of Q (every) 15 minute checks around the clock. Staff to resident assignment for closer supervision, monitoring and/or observation reference to but not limited to: impulsiveness at times. The goal was Will have no adverse outcomes/injuries through next review date. The interventions were not revised to reflect the change of level of supervision from 1:1 to Q 15 minute checks. Interventions still included The staff member assigned to the q 15 minutes around the clock checks will accompany the resident at all times (including bathing, showers, meals, toileting and off - unit activities). Resident will be within arm's reach at all times, even while sleeping; The staff member assigned to Q 15 minutes checks around the clock will not leave the resident at any time without a replacement staff member in place (breaks, meals, restroom, change of shift). The resident will not be left alone at any times; Staff member performing Q 15 minute around the clock will report to nurse any behaviors or changes in condition immediately; Try alternative measures to encourage relaxation and or provide distraction. In the assessment section of Resident # 3's record was a form, dated [DATE], entitled Evaluation of Need for Specialized Supervision, Observation and/or Monitoring, completed by the Risk Manager. Review of the form revealed yes responses were checked for the resident in reference to Is the resident non- adherent to safety interventions? and Does the resident have any other socially inappropriate behavior that poses a risk to self or others (i.e. public disrobing, rummaging in other's belongings, etc.?) A narrative comment revealed Resident who has extreme impulsivity will stand unassisted and attempt to walk & falls. She is unable to be left unattended so she is currently on 1: 1. Summary of findings and recommendations revealed Continue 1: 1 supervision and there were checkmarks for 1: 1 Nursing Staff Supervision Around the Clock. Review of the record revealed that Resident # 3 remained on 1: 1 supervision after this assessment until another assessment was completed just seven days later. Review of an Evaluation of Need for Specialized Supervision, Observation and/or Monitoring dated [DATE] revealed a yes response for the question Is the resident non - adherent to safety interventions? Review of the narrative comments revealed Resident currently on 1: 1 supervision. She has had minimal needs of redirection as per 1: 1 supervision monitoring sheets. Evaluation conducted on [DATE] from 9: 30 -10: 00, Zero impulsive movements noted at this time. Will call MD (Medical Doctor) and suggest Q 15 minutes check around the clock to see if we can reduce the 1:1. Tools used: Observation sheets over 2 months, staff interviews, and current assessment. Summary of Findings and Recommendations revealed Resident noted during a 30 minute observation period to have zero impulsive moments. 11 to 7 staff reporting zero attempts to rise at night and per 1:1 observation sheets she has moments of needed redirection that are successful. Will attempt reduction of 1:1 to Q 15 minute checks if MD agrees. Date physician notified: [DATE]. Physician orders [REDACTED]. Start Q 15 minute checks around the clock and may not be in room alone while up in wheelchair. Review of Nurse's notes in the resident's chart revealed an entry signed by the Risk Manager, for [DATE] at 10:00 a.m., which stated, Resident observed for possibility of decrease from 1:1 to Q 15 minute checks. Per log book, has minimum episodes of impulsivity and when she does redirection is + (positive). Resident sitting at nurses station up in wheelchair sitting well speaking with staff and residents that pass by. Zero moments of impulsivity. Spoke with POA (Power of Attorney) who agrees with reduction to Q 15 minute checks, MD agreed as well. Order noted to D/C 1:1, Start Q 15 minute checks ATC (around the clock). Possible for activity tray as resident likes books and magazines and a lap tray would facilitate this. Will Monitor. A second Nurse's note, written by the Risk Manager and dated [DATE] at 2:00 p.m. revealed, Full lap activity tray added to promote independent activities while up in wheelchair, MD and family aware. A Physical Restraint Elimination Assessment form was completed by the Risk Manager on [DATE]. Instructions on the form indicate Restrained individuals should be reviewed AT LEAST QUARTERLY to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or a total restraint elimination. For each category listed below, assess the resident by circling the corresponding score that best describe his/ her current status in the appropriate assessment column. Add the column of numbers to obtain the score. Review of the responses on the form revealed that responses were circled for: Ambulation - Ambulates with assist of two, Weight Bearing - full weight bearing, Sitting balance - leans to a side, forward, backward and slides down. ADLS - Requires total assist of two Physical Limitations - History of falls Vision status - adequate with glasses/without glasses Orientation - Disoriented (x 2 spheres) Comprehension - Directions must be frequently repeated Behavior/ Mood - Exhibits / Expresses fears or anxieties Activity Participation - Participates with assistance Medication Therapy - Not taking any chemical restraint. The total score was recorded as 18 and the scoring directions indicated a score of 0 - 20 was a Priority Candidate. Review of the assessment revealed: 1. Candidate Status as determined by Total Score on reverse - checked as Priority. 2. Candidate for restraint reduction or elimination program - choice of yes or no check box, no response documented If yes, Date program to start: [DATE] Action Plan: Not a Restraint. 3. Additional Comments: This is an Activity tray that resident can remove. Review of physician telephone orders for [DATE] revealed an order with no time noted for 1. D/C all orders r/t 1: 1 Supervision. 2. Start Q 15 minute checks ATC. (Around the Clock) A second order with no time noted, also dated [DATE], stated Resident may have an Activity Full Lap tray to promote independence with activities. Check Q 30 minutes and remove Q 2 hours and PRN (as needed) for Group Activities, Meals, ADLS and Toileting. An interview was conducted with the Risk Manager, on [DATE] at 1:32 p.m. regarding reducing the level of supervision for Resident # 3 from 1: 1 supervision to every 15 minute checks on [DATE]. She stated She was 18 months on 1:1, we would review her regularly and she started showing improvement at the end. She stated she looked at the 1:1 log sheets, looked at the resident. She stated the day I assessed her was following no behavior for several days. The Risk Manager stated she reviewed documentation back to [DATE] and there had been no incidents and no attempts to get up. She stated she spoke with the resident's daughter, told her she had noticed an improvement and the daughter told her let's try this. She stated that she assured the daughter she wouldn't hesitate to put her back on 1:1 if she needed it. She stated she discussed it with Resident #3's physician and he agreed and gave the order to discontinue to 1:1 supervision and start every 15 minute checks. The Risk Manager stated she noticed that the resident wanted a book or a magazine in her hands and sat in her wheelchair with her legs crossed. And she got her an activity tray that she could take on and off. The Risk

Based on record review, policy and procedure review, staff and administrative interviews, and job description review, it was determined that the facility failed to be managed in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for two of fourteen residents ( # 3, # 4) related to supervision needs. The Administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and did not utilize the processes in place to ensure the facility did not neglect to provide supervision. Record review and interview indicated Resident # 3 was an [AGE] year old long term care resident with [DIAGNOSES REDACTED]. The facility chose to discontinue one to one around the clock supervision of Resident # 3 and reduce the level of supervision to every fifteen minute observations. The facility ' s licensed nurse chose to leave Resident # 3 alone, unsupervised and unattended in the hallway of the facility in the middle of the night in spite of the licensed nurse ' s knowledge of the resident ' s attempts to get out of bed and impulsive and restless behavior. The resident fell , alone and unsupervised, hit her head and sustained a subarachnoid hemorrhage and subsequently died . Documentation and interview for Resident # 4 indicated that the resident was actively dying, restless and anxious and had attempted to get up. Yet the facility staff failed to document any attempts to alleviate her symptoms and provide comfort, monitoring and supervision. The resident was found on the floor, alone, next to her bed, with her head on the metal frame of the over bed table and a pool of blood under her head. The resident died on the floor of her room with emergency services present. The failure of the facility's Administration to meet its obligation to provide the level of oversight necessary to ensure the safety and well-being of residents resulted in Past Non-Compliance at the Immediate Jeopardy level identified on [DATE] as occurring on [DATE]. The Administrator was notified on [DATE] at 6:10 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings included: 1. Review of the Administrator ' s Job Description signed (undated) by the Administrator revealed the following information: Job Title Administrator ; Department : Administration; Definition: The person responsible for the overall operation of the facility General Job Summary: The Administrator delegates the overall operational responsibility for the efficient operation of the entire facility in accordance with the general objectives, policies and established philosophy. Has principle responsibility for the total optimum care of the residents and for the general welfare conditions of the employees. Places major emphasis on program development and coordination of services. Specific duties include but not limited to: #14. Complies with local, state and federal licensing standards and regulations. #23 and #29. Enforces the rules and regulations relative to the level of health care and safety of residents, and to the protection of their personal and property rights. 2. On [DATE] at 1: 32 p.m., the Administrator, Director of Nursing (DON) and Risk Manager where asked to provide information regarding the facility ' s fall precautions, levels of supervision including 1: 1 supervision and frequent safety checks, care plan concerns and the investigation and outcome related to the fall for Resident # 3. The Administrator, while present for the discussion, did not speak or offer any information. Subsequently, on [DATE] at 9: 19 a.m., the Administrator, DON and Risk Manager were asked to discuss with the surveyor the concerns identified related to Resident # 3 and Resident # 4 and any additional measures or corrective action that was put in place after the falls for these residents. The Administrator was present for this discussion, but did not speak or offer any information, from 9: 18 a.m. until 9: 42 a.m. At 9: 42 a.m. he excused himself from the room and stated he had to be on a conference call. He did not return nor did he offer any additional information on these topics for the remainder of the investigation. 3. Review of the record for Resident # 3 revealed the following Narrative Nursing notes commencing at 11:00 p.m. on [DATE] and written by Employee A, a Licensed Practical Nurse (LPN): [DATE] 11:00 p.m. Resident in bed, respirations even and unlabored. No distress noted. Call light in reach. Continues on every (Q) 15 minutes checks for safety precautions. [DATE] 11:15 p.m. Trying to get OOB (Out Of Bed) - assist up to wheelchair (W/C) by Certified Nursing Assistant (CNA) and full lap tray applied and was brought out into hallway. Resident sat in W/C with CNA on A Hall. Magazines given to her to distract her. [DATE] 11:45 p.m. Continues to sit in W/C next to CNA on A-Hall. Resident takes her Full lap tray off and puts it on Floor next to her. CNA talks to resident and asks her if she can reapply Full lap tray and she states yes. Full lap tray reapplied on W/C. Magazines given, snacks offered, toileting offered. No distress noted. [DATE] 12:15 a.m. Continues to sit in W/C next to CNA on A-Hall. Resident continues to take Full lap tray off and CNA continues to redirect and put lap tray back on and offer magazines, and snacks and conversation with resident to distract her. No distress noted. [DATE] 12:30 a.m. CNA brought resident to me near nurse ' s desk. Sitting in W/C in Front of her room. Resident put magazines in her lap and pulled lap tray off W/C and put in the Floor next to her. This nurse walked over to her and asked if I could put lap tray back on her W/C and resident states Yes. Full lap tray reapplied. Asked resident if she wanted a snack or needed to go to the bathroom and she states No. No distress noted. [DATE] 12:40 a.m. Resident continues to sit in her W/C in hallway and continues to take Full lap tray off of her W/C. This nurse continues to redirect. Asked resident if she was tired and wanted to go to bed- she states No. [DATE] 12:45 a.m. Resident continues to sit in her W/C in hallway in Front of her Room. Resident continues to take her Full lap tray off of W/C and this nurse continues to put back on with her permission. Asked resident again if she was ready for bed, she states No. I told her I needed to step next door to another patient ' s room and I would be back in a minute or two. She states Okay. [DATE] 12:50 a.m. CNA reported that resident was on the Floor. When coming out of another patients Room and into Hallway resident was laying in the Floor across the hall from her W/C lying face down with right side of her face against the floor. Small puddle of blood noted under her head. Small laceration noted to Right temple. After looking over her body-No other injuries noted. Log rolled her over to better evaluate her, did hear her moan and respond. [DATE] 01:00 a.m. Vital Signs (VS)= ,[DATE] - 98 - 79 - 20. Neurologic check done. Alert but drowsy, PERL (Pupils Equal, React to Light), Able to move extremities, when asked if she is having pain does not answer. Laceration to Right temple cleaned with Normal Saline (NS) and patted dry, steri strips applied and dry dressing applied. Transferred from Floor to W/C with assist of 2 people plus myself. Wheeled to bed and put back to bed to continue monitoring- 1:1 supervision initiated by this nurse. CNA at bedside with resident. [DATE] 01:15 a.m. Restless in bed. VS =,[DATE] - 98 - 79 - 20. Neurologic check done. Alert, Left Pupil reactive, Right Pupil not reactive. Able to move all extremities. Dressing to Right temple dry/intact. Pupils checked by 2nd nurse - Right side not reacting. (Physician) phoned and notified of fall with laceration to Right temple and that Left pupil reacting but Right pupil non-reactive. Orders received to send out to Hospital for Evaluation and treatment. Orders written. [DATE] 01:30 a.m. Called 911 for transport to Hospital after necessary paperwork copied and prepared. [DATE] 01:35 a.m. Ambulance and Emergency Medical Technician (EMT)/Paramedics here to pick up patient. All necessary paperwork given to them. History and report given to them. [DATE] 01:40 a.m. Patient left facility via stretcher with EMT personnel without incident going to Hospital by ambulance. [DATE] 01:42 a.m. Called Hospital ER and spoke to nurse and gave her report and history on patient. [DATE] 01:45 a.m. (Family) called and notified of fall with laceration to Right temple and patient was transferred to Hospital. [DATE] 01:47 a.m. Called Risk Manager to notify of patient fall received voicemail left message. [DATE] 04:10 a.m. (Family) called this Facility to let us know patient was admitted to Hospital and she was in Intensive Care Unit (ICU) with bleed in her brain . Review of a hospital record for [DATE] revealed that Resident # 3 was transferred by Air ambulance from the first hospital to a second hospital for neurosurgical evaluation and admission for critical care. Review of the Admission History and Physical in the emergency department for the second hospital for [DATE] revealed: The patient presents with [AGE] year old Caucasian female sent here from (first hospital) for cerebral bleed, patient has a subarachnoid hemorrhage on CT done at 0300 . She fell while sitting in a wheelchair at the nursing home (NH), has a laceration to the right supraorbital area and right upper eyelid. Physical examination, on [DATE], stated Neurologic - Intubated, sedated. Impression and Plan: admitted on [DATE] post fall from chair at NH, Found to have: SAH (Subarachnoid Hemorrhage) - on [MEDICATION NAME]. Review of the facility ' s physician's order [REDACTED]. According to www.PDR.net (Physician ' s Desk Reference) [MEDICATION NAME] is an Antiplatelet agent and side effects include increased risk of bleeding. The brand name for [MEDICATION NAME] is [MEDICATION NAME]. Continued review of the hospital record indicated the patient was admitted to the Intensive Care Unit. Review of the Discharge Summary - Death Summary , dated [DATE] revealed, Hospital Course: [AGE] year old Caucasian female sent here from (name of first hospital) for cerebral bleed. The patient has a subarachnoid hemorrhage on CT done at 0300. Discussion with the patient ' s power of attorney noted that the patient is a do not resuscitate but would want surgical intervention if it could potentially help her and/or transfusion if necessary. She would not want Cardio [MEDICAL CONDITION] Resuscitation (CPR), electrical defibrillation or other resuscitative measures. The patient would want her Do Not Resuscitate (DNR) to stay in place. The patient arrived intubated and the power of attorney is aware of this. The patient is a former registered nurse with a history of dementia, incontinence of urine and has been at the nursing home about a year. She fell while sitting in a wheelchair at the nursing home. There was a laceration to the right supraorbital area and right upper eyelid. The nursing home staff had left then came back to find the patient on the ground with cut around the lateral area to the right eye. [DATE]: Sent from (first hospital) for SAH (Subarachnoid Hemorrhage) from fall out of wheelchair. CT head with contrast: several small to mod - sized foci of extra - axial hemorrhage, mainly in the sulci to frontal, parietal and temporal lobes, lacerations right supraorbital area and right upper eyelid closed in Emergency Department (ED) [DATE] Remains on mechanical vent but neuro is improving - failed SAT/SBT (Spontaneous Awakening Trial/Spontaneous Breathing Trial). [DATE] Daily SAT/SBT, patient does well on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) but not awake enough to protect airway. [DATE] Spoke with (family) and the plan is that family will most likely arrive in the next few days for eventual extubation with full DNR. If patient can awaken and protect her airway . fine, but if she cannot maintain off mechanical vent, then comfort care will be provided. [DATE] Patient becomes restless and coughs when sedation levels dropped but does not awaken/ follow commands. [DATE] No clinical change to suggest that patient can now protect airway. [DATE] On vent and not responsive and started Enteral tube feeds. [DATE] On vent and not fully alert and failed SBT. (Physician) discussed and explained to (family) about her medical problems, plan of care and prognosis. (Family) made a decision that they wanted to withdraw life support ventilator and stopped all her medications except comfort measures. She was extubated and on intravenous (IV) [MEDICATION NAME] and IV [MEDICATION NAME] and died in TICU. Family members at bedside. Preliminary cause of death listed (included but not limited to): Several small to moderate - sized foci of extra- axial hemorrhage. Hemorrhage mainly in the sulci of frontal lobes, parietal and temporal lobes. Therefore hemorrhage is likely mainly in the subarachnoid space. Most prominent foci of hemorrhage appears to be the frontal lobes and right temporal lobes after fall in nursing home from chair and she was on [MEDICATION NAME]. Acute Respiratory insufficiency, requiring mechanical ventilator and intubated on ,[DATE] and failure to wean off due to AMS (Altered Mental Status) and inability to protect airway . On [DATE] at 8:47 a.m. an interview was conducted with Staff A, the LPN who worked with Resident #3 on the 11 p.m. to 7 a.m. shift on [DATE] and wrote the nursing notes for [DATE] and [DATE]. She stated that when she came on shift for the 11:00 p.m. to 7:00 a.m. shift on [DATE]; Resident #3 was restless in the bed and not sleeping. Staff A stated they got her up in the wheelchair, put the lap tray on and brought her out in the hallway. Staff A stated she was afraid the resident would try to get up and was told not to leave her in her room alone; thus she brought her out in the hall to keep a close eye on her. Staff A stated she ' d been with someone by her side for so long. Staff A stated the resident kept taking the tray off, but never tried to get out of her chair. Staff A indicated that she and the aide would watch her and stated I had her close to the desk with me when (Staff B) went on break. Staff B brought her to me; I was doing paperwork at the desk. She stated that she had to go in to check on a resident in another room, and she parked her in front of her door, told her what I was doing and would be right back. She was parked facing the nurse ' s station at her room and I stepped into the room next door. She stated when Staff B came back to the floor after her break, she told her that Resident #3 was on the floor. Staff A stated I did not hear her get up or hear her go down. Staff A stated she had just gotten the blood pressure cuff on the other resident when she heard staff B say the resident was on the floor. She stated, Her chair was by the door when I came out, she was lying diagonally in front of the wall across the hall . She stated the resident was face down with her head turned to the right and did not know how the resident got in that position. When asked if there were any other staff in the area when the resident fell she stated not that I know of. Staff A confirmed she came out to assess Resident #3 who was on the floor. She stated there was a little blood under her from the cut, superficial. She was crying a little bit. She stated that she and a Registered Nurse (RN/Staff C) checked the resident ' s vital signs and did neurologic checks. She stated the vital signs and neurologic checks were okay and between the two of us, felt comfortable, she only needed steri strips, no other injuries, she was crying. She stated they got her off the floor, placed her in her wheelchair and then in her bed and did neuro checks again. She stated, at that time, the neuro checks were abnormal; one pupil was not reacting, dilated and not responding . She stated she called the physician and received the order to send her to the hospital via 911. Staff A stated she had provided care for Resident #3 regularly on the 11 p.m. to 7 a.m. shifts. When asked to describe Resident # 3, she stated Some nights she was quiet and slept comfortably. Other times she was fidgety. Some nights she didn ' t sleep well, was fidgety and nervous when she was awake, we would put her in her chair, bring her out to the hall, let her socialize, give her a drink, magazines, then she would go back to sleep. An interview was held with Staff B, the CNA who provided care for Resident #3 on the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Staff B stated she had worked with Resident #3 since she came here and had provided 1:1 supervision to the resident in the past. She stated she was concerned that every 15 minute checks were not going to work for Resident #3. She stated Everyone knew it was going to be a problem. She stated, She was only every 15 minute checks, my main focus was on her. My first night having her off 1:1, I thought, this isn ' t going to work. I felt like I had to watch her every minute still. She stated she was climbing out of bed when I first came in that night. She was still the same, she had not gotten any better. When asked what the resident was like when she provided 1:1 supervision for her in the past, she stated She was restless, trying to get up, had to redirect her. Restless, tossing, turning, trying to get up, grabbing, and that she would bring her out of her room into the hall. Staff B stated when she came on shift, she does not recall if the resident was in bed. She stated when the resident was up in the hallway in her wheelchair, she stayed with her. She stated there was an activity tray on her wheelchair, she was trying to take it off, trying to get up, and she was very very busy when I was with her- I stayed with her. She stated that when she went on break, she told Staff A that she was going on break and brought Resident #3 to Staff A at the nurses ' station. She stated Q 15 minutes wasn ' t going to work, that it is why when I went on break I had her covered. Staff B stated when she returned from her break, she saw Resident # 3 on the floor. She stated no one was with her and she saw no staff in the hall. Staff B stated she alerted Staff A, who was in the patient ' s room next door. Staff B described Resident #3 as screaming, yelling and very agitated. She stated she asked her if she was hurt, then she saw the blood. She stated she does not know where the lap tray was, thinks it was off to the side somewhere. She stated Resident #3 was in the hallway outside of her door when she found her and Staff A was taking care of another patient in another room. An interview was held on [DATE] at 10:15 am with Staff C, the RN who assisted Staff A, after Resident #3 was found on the floor. During the interview, Staff C stated she was on another hall in Station 1 at the treatment cart with her back turned to the hall Resident #3 was on. Staff C was the RN supervisor on that shift and stated she heard someone say there she goes but did not know who that was. When asked to describe Resident #3 the night prior to the fall, Staff C stated She needed to be attended to, she still needed constant supervision because of impulsiveness and lack of understanding. Staff C stated that she and Staff A initially assessed the resident ' s vital signs and conducted neuro checks, looked for bleeding and bruising. She stated she (Resident #3) was making a strange sound, sort of a screeching, a different sound, a screeching sound . She stated that they placed her in her wheelchair, put her in her bed and started neuro checks again. She stated we knew she needed to go out because of her behavior and her right pupil started to be non-reactive. She was responsive, crying a little bit. On [DATE] at 6: 25 p.m. an interview was held with Staff D, an LPN who stated she provided care routinely for Resident #3 on the 3 p.m. to 11 p.m. shift. Staff D stated she was not working the day that Resident #3 fell . She stated, They had put her on 1: 1 for a long time, she was under our close watch and She tried to get up, that is why we kept a watch on her. Staff D stated, In the days before she fell , she was still trying to get up, so we had to watch her close. On [DATE] at 9:55 a.m. an interview was conducted with Staff E, a CNA who stated she had provided 1:1 supervision for Resident #3. Staff E described Resident #3 as In the beginning she was very restless, trying to jump up and we would have to redirect her. She would hear something in the hall, wanted to bake a cake. Toward the end, it wasn ' t as much but once in a while she would try and get up from her chair. A phone interview was conducted with Resident #3 ' s physician on [DATE] at approximately 8:20 a.m. The physician stated that the facility usually lets him know when they are going to increase or decrease the level of supervision for a resident, but he could not recall if he was informed for Resident #3 and stated it was a long time ago. The physician stated Resident #3 was on 1:1 for almost the majority of the time since her admission to the facility, behavior had improved, and she no longer needed that particular supervision. He stated the family was notified of the change in the supervision. The physician concluded the resident was able to be by herself without someone right with her, but unfortunately she fell . Review of documentation for Q 15 minute checks for Resident #3 for [DATE] revealed that from 9:30 a.m. to 8 p.m., the resident was noted to be at the Station 1 Nursing Station the majority of the time. At 8: 15 p.m., she was noted to be in the bathroom and from 8:30 p.m. to 11 p.m., she was documented as being in bed. Documentation from 11:15 p.m. to 11:30 p.m. revealed the resident ' s location was noted to be up in wheelchair (W/C). From 11:45 p.m. on [DATE] to 12:30 a.m. on [DATE], the resident ' s location was documented as W/C A Hall. At 12:45 a.m., Staff B, the Certified Nursing Assistant (C.N.A.) who provided care for this resident during the 11 p.m. to 7 a.m. shift on [DATE], had documented the resident ' s location as Floor. This was written over by Staff A, the Licensed Practical Nurse (LPN) who provided nursing care for the resident on [DATE] on the 11 p.m. to 7 a.m. shift. Employee A, wrote in wheelchair over Staff B ' s entry of Floor, and initialed the change. Documentation for 1:00 a.m. indicated the resident ' s location was Floor and at 1:15 a.m., the documentation indicated the resident ' s location was Floor. Record review for Resident # 3 revealed that she was admitted to the facility on [DATE]. Review of the Client [DIAGNOSES REDACTED]. Continued review of the record revealed that Resident #3 sustained two falls in early 2015: on [DATE] and [DATE]. The resident was placed on one to one supervision in [DATE] and remained on one to one supervision from [DATE] until approximately 10:00 a.m. on [DATE]. Review of an annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a score of 3 (indicating Severe Cognitive Impairment) on the Brief Interview for Mental Status (BIMS) assessment. The resident was coded as needing extensive assistance of two persons for bed mobility and transfer, extensive assistance of one person for ambulation and total dependence for locomotion. Balance during transition and walking was coded as not steady, only able to stabilize with human assistance and the resident utilized a wheelchair for locomotion. Review of a Summary of Plan of Care , completed by a registered nurse on [DATE] revealed: Provide ½ side rails x 2 as enabler, geo mattress, w/c cushion, off load heels when in bed, provide 1: 1 increased observation 7 days/ week by facility staff due to impulsiveness /[MEDICAL CONDITION].Speech is clear but she appears confused and does not answer my questions appropriately . Requires 1: 1 supervision ,[DATE] due to impulsiveness and poor safety awareness. The Narrative summary includes Transfers with 1 person assist. Uses the w/c for mobility and it is propelled by staff. Review of Care plans for Resident #3 revealed a care plan, dated [DATE] and last reviewed [DATE] for a problem of risk for falls/injuries related to: [MEDICAL CONDITION], Decreased Activities of Daily Living (ADL ' s), Impaired Hearing, Impaired Memory, Impaired Vision, Unsteady Gait, and history of falls. Goals were listed as Will have as close to no falls possible by managing risk factors, if fall occurs, will have minimal injuries related to falls through next review. Fall risk Score 90 = High risk. Interventions included: Remind not to stand without assistance or use of assistive device if utilized; Use gait belt when helping to ambulate/transfer; Instruct/reinforce safety measures with ( resident )/ family such as transfer techniques, proper foot wear, locking wheelchair; Keep call light within reach; Encourage to ask for assistance as needed; Falling precautions program: if fall score is 25 or higher will use yellow wrist band; Monitor for changes in ADL ' s Cognition, Behavior, Mood and Medications for Potential Risk Factors; Staff will be responsive to individual hearing, vision or communication concerns (keep room and hallways free from hazardous objects/clutter, adequate lighting, reduction of background noise); Keep bed in lowest position to the floor when care is not being rendered and lock bed wheels at all times. A new care plan was written [DATE], when the resident was changed from 1: 1 supervision to every 15 minute checks, which listed a problem of Is in need of Q (every) 15 minute checks around the clock. Staff to resident assignment for closer supervision, monitoring and/or observation reference to but not limited to: impulsiveness at times. The goal was Will have no adverse outcomes/injuries through next review date. The interventions were not revised to reflect the change of level of supervision from 1:1 to Q 15 minute checks. Interventions still included The staff member assigned to the q 15 minutes around the clock checks will accompany the resident at all times (including bathing, showers, meals, toileting and off - unit activities). Resident will be within arm ' s reach at all times, even while sleeping; The staff member assigned to Q 15 minutes checks around the clock will not leave the resident at any time without a replacement staff member in place (breaks, meals, restroom, change of shift). The resident will not be left alone at any times; Staff member performing Q 15 minute around the clock will report to nurse any behaviors or changes in condition immediately; Try alternative measures to encourage relaxation and or provide distraction. In the assessment section of Resident # 3 ' s record was a form, dated [DATE], entitled Evaluation of Need for Specialized Supervision, Observation and/or Monitoring, completed by the Risk Manager. Review of the form revealed yes responses were checked for the resident in reference to Is the resident non-adherent to safety interventions? and Does the resident have any other socially inappropriate behavior that poses a risk to self or others (i.e. public disrobing, rummaging in other ' s belongings, etc.?) A narrative comment revealed Resident who has extreme impulsivity will stand unassisted and attempt to walk & falls. She is unable to be left unattended so she is currently on 1: 1. Summary of findings and recommendations revealed Continue 1: 1 supervision and there were checkmarks for 1: 1 Nursing Staff Supervision Around the Clock. Review of the record revealed that Resident # 3 remained on 1: 1 supervision after this assessment until another assessment was completed seven days later. Review of an Evaluation of Need for Specialized Supervision, Observation and/or Monitoring dated [DATE] revealed a yes response for the question Is the resident non - adherent to safety interventions? Review of the narrative comments revealed Resident currently on 1: 1 supervision. She has had minimal needs of redirection as per 1: 1 supervision monitoring sheets. Evaluation conducted on [DATE] from 9: 30 -10: 00, Zero impulsive movements noted at this time. Will call MD (Medical Doctor) and suggest Q 15 minutes check around the clock to see if we can reduce the 1:1. Tools used: Observation sheets over 2 months, staff interviews, and current assessment. Summary of Findings and Recommendations revealed Resident noted during a 30 minute observation period to have zero impulsive moments. 11 to 7 staff reporting zero attempts to rise at night and per 1:1 observation sheets she has moments of needed redirection that are successful. Will attempt reduction of 1:1 to Q 15 minute checks if MD agrees. Date physician notified: [DATE]. Physician orders [REDACTED]. Start Q 15 minute checks around the clock and may not be in room alone while up in wheelchair. Review of Nurse ' s notes in the resident ' s chart revealed an entry signed by the Risk Manager, for [DATE] at 10:00 a.m., which stated, Resident observed for possibility of decrease from 1:1 to Q 15 minute checks. Per log book, has minimum episodes of impulsivity and when she does redirection is + (positive). Resident sitting at nurses station up in wheelchair sitting well speaking with staff and residents that pass by. Zero moments of impulsivity. Spoke with POA (Power of Attorney) who agrees with reduction to Q 15 minute checks, MD agreed as well. Order noted to D/C 1:1, Start Q 15 minute checks ATC (around the clock). Possible for activity tray as resident likes books and magazines and a lap tray would facilitate this. Will Monitor. A second Nurse ' s note, written by the Risk Manager and dated [DATE] at 2:00 p.m. revealed, Full lap activity tray added to promote independent activities while up in wheelchair, MD and family aware. A Physical Restraint Elimination Assessment form was completed by the Risk Manager on [DATE]. Instructions on the form indicate Restrained individuals should be reviewed AT LEAST QUARTERLY to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or a total restraint elimination. For each category listed below, assess the resident by circling the corresponding score that best describe his/ her current status in the appropriate assessment column. Add the column of numbers to obtain the score. Review of the responses on the form revealed that responses were circled for: Ambulation - Ambulates with assist of two, Weight Bearing - full weight bearing, Sitting balance - leans to a side, forward, backward and slides down. ADLS - Requires total assist of two Physical Limitations - History of falls Vision status - adequate with glasses/without glasses Orientation - Disoriented (x 2 spheres) Comprehension - Directions must be frequently repeated Behavior/ Mood - Exhibits / Expresses fears or anxieties Activity Participation - Participates with assistance Medication Thera

Based on resident record review, policy and procedure review and staff interviews, it was determined that the facility's Quality Assessment and Assurance (QAA) Committee, failed to ensure that measures which had been in place to prevent falls continued to be implemented and improved upon for two (#3, #4) of fourteen residents reviewed for supervision. The facility failed to have an effective QAA committee that identified, developed and implemented appropriate corrective action plans to address neglect and supervision issues. The facility failed to ensure their policies were in compliance with Federal regulations/guidance, failed to monitor staff performance and failed to analyze the root cause to facilitate program changes. The facility's failure to identify quality deficiencies and failure to develop and implement appropriate plans of action to correct identified deficiencies regarding neglect and supervision resulted in Resident #3 sustaining a fall with subsequent death and Resident #4 found on the floor of her room, alone, in a puddle of blood and subsequently died within 30 minutes of the event. On [DATE] Immediate Jeopardy was identified at F 224, F 226, F 323, F 490 and F 520. This Immediate Jeopardy related to neglect and adequate supervision for a resident (identified as Resident #2 on the [DATE] survey) who lacked safety awareness and had a need for increased supervision. This resident sustained [REDACTED]. The facility failed to demonstrate that the identified actions included in the plan of correction from [DATE] were continued to ensure residents received the appropriate level of supervision and monitoring: On [DATE], the facility chose to discontinue one to one constant supervision around the clock for Resident # 3, an [AGE] year old long term care resident with [DIAGNOSES REDACTED]. The facility chose to reduce the level of supervision from one to one to every 15 minute checks, which only required staff to observe the resident at least every fifteen minutes. The resident fell sustaining a subarachnoid hemorrhage within 12. 5 hours of the one to one supervision being discontinued. The facility ' s licensed nurse failed to increase the level of supervision to ensure Resident #3 ' s safety and well-being, in spite of the resident ' s attempt to get out of bed on her own and documented restlessness and impulsivity, instead leaving her alone in the hallway where she attempted to rise and fell , hitting her head, and sustaining a subarachnoid hemorrhage leading to her subsequent death. On [DATE] and [DATE], the facility failed to provide increased supervision, monitoring or support for Resident #4 who was reported as actively dying, restless and anxious. The facility ' s licensed nurses were aware of the resident ' s condition and reports that she had tried to get up on her own yet they failed to document any attempts to alleviate her symptoms and provide comfort and supervision to Resident # 4. The resident was found on the floor, alone, next to her bed, with her head on the metal frame of the over bed table and a pool of blood under her head. The resident died on the floor of her room with emergency services present. Past Non-Compliance at the Immediate Jeopardy level was identified on [DATE] as occurring on [DATE]. The Administrator was notified on [DATE] at 6:10 p.m. The Immediate Jeopardy was determined to be corrected on [DATE], prior to the facility visit. Findings Included: 1. A review of the facility ' s Plan of Correction for F 323 from the survey ending [DATE] revealed the following measures were implemented to ensure compliance: The development of a policy and procedure on 1:1 and 1: 2 Nursing Staff to Resident Evaluation and Assignment which was approved by the Administrator and Medical Director on [DATE] and revised on [DATE]. The procedure portion provided guidance to the nursing staff to follow when evaluating the need for increased supervision, monitoring and or observation and training for nursing staff on providing increased supervision, monitoring or observation. The development of a tool entitled Evaluation of Need for Specialized Supervision, Observation and /or Monitoring on [DATE], revised on [DATE], contained information on what types of conditions and/or behaviors may warrant the need for specialized supervision, observation and/or monitoring. The Plan of correction stated the facility recognizes that there are times when a resident requires increased supervision, observation and/or monitoring on an immediate basis in the nurse ' s clinical judgement. The development of a Review of Resident ' s Response to Specialized Supervision, Observation and/or Monitoring tool on [DATE] and revised on [DATE]. This tool was developed for reviewing the level of supervision already in place. This tool guided licensed nurses to review the resident ' s response to specialized supervision, observation and/ or monitoring and to make recommendations to address the resident ' s needs including 1) improving or worsening condition and/ or the emergence of a new condition or risk that may indicate the need for specialized supervision /and or monitoring, 2) whether or not the resident needed a new evaluation for specialized supervision , observation and/or monitoring, 3) whether or not the care plan needed revision, and 4) whether or not a referral for an Interdisciplinary Team ( IDT ) review was needed. Training was provided to the facility licensed nurses by the Director of Nursing on [DATE] and to the Certified Nursing Assistants on [DATE] and [DATE]. Training content included a review of the policies and procedures for 1: 1 and 1: 2 Nursing staff to Resident Evaluation and Assignment, indications that might require increased supervision and/ or monitoring, providing assistance with Activities of Daily Living (ADLS) and not leaving the resident alone unless replaced by another staff member. Training on 1: 1 would be provided annually thereafter and at new employee/orientation. 2. Review of the Facility ' s Quality Assurance /Risk Management and Performance Improvement policy, undated and unsigned, revealed: Policy: The facility is committed to the pursuit of excellence in the provision of quality of care and services to facility residents. The facility will maintain a Quality Assurance/Risk Management Performance Improvement Committee in accordance with Federal and state regulations. The committee will oversee quality, risk management and performance improvement activities at the facility including oversight of the delivery of resident care services that meet the unique needs of the individual in an environment which promotes meeting or exceeding current long term care practice standards. Procedure: 1. Authority : The Administrator has the ultimate responsibility to establish, maintain and direct the committee. 2. Scope: The committee will monitor a centrally coordinated program of quality assurance, risk management and performance improvement that is ongoing and systemic and one that includes plans of action and evaluation of such plans. Activities will be integrated and coordinated among all departments to avoid duplication of efforts. 3. Organization: The main committee will be comprised of the Administrator, Director of Nursing, Risk Manager, Department leadership representatives and physician. 8. Performance Improvement Plans/ Projects: The Committee will utilize performance improvement plans/projects(PIPS) to review and improve care as well as financial and regulatory issues. 9. Systemic Analysis and Systemic Action: the committee may choose from a variety of systemic approaches such as Root Cause analysis, Plan Do Study Act and Look, Think, Talk, Decide, Do, and Look again. These examples are suggestive approaches and do not imply that these are the only approaches that the Committee may choose to use in undertaking their responsibilities. 10. Reports: the Committee will oversee and monitor the development, implementation and evaluation of performance improvement plans via a tracking log. The committee will monitor for progress and resolution where areas of opportunity are identified. Where there is a lack of progress, the Committee will review for changes in the corrective action and/or performance improvement plan and make revisions as necessary. The Risk Manager, on [DATE] at 9: 18 a.m. stated there was an ongoing performance Improvement plan for falls. An interview was conducted with the Medical Director, on [DATE] at 10: 35 a.m. He stated he attends the Quality Assurance meetings and stated that falls are discussed by the committee. 3. Review of the record for Resident # 3 revealed the following Narrative Nursing notes commencing at 11:00 p.m. on [DATE] and written by Employee A, a Licensed Practical Nurse (LPN): [DATE] 11:00 p.m. Resident in bed, respirations even and unlabored. No distress noted. Call light in reach. Continues on Q (every) 15 minutes checks for safety precautions. [DATE] 11:15 p.m. Trying to get OOB (Out Of Bed) - assist up to W/C (wheelchair) by Certified Nursing Assistant (C.N.A.) and full lap tray applied and was brought out into hallway. Resident sat in W/C with CNA on A Hall. Magazines given to her to distract her. [DATE] 11:45 p.m. Continues to sit in W/C next to CNA on A-Hall. Resident takes her Full lap tray off and puts it on Floor next to her. CNA talks to resident and asks her if she can reapply Full lap tray and she states yes. Full lap tray reapplied on W/C. Magazines given, snacks offered, toileting offered. No distress noted. [DATE] 12:15 a.m. Continues to sit in W/C next to CNA on A-Hall. Resident continues to take Full lap tray off and CNA continues to redirect and put lap tray back on and offer magazines, and snacks and conversation with resident to distract her. No distress noted. [DATE] 12:30 a.m. CNA brought resident to me near nurse ' s desk. Sitting in W/C in Front of her room. Resident put magazines in her lap and pulled lap tray off W/C and put on the Floor next to her. This nurse walked over to her and asked if I could put lap tray back on her W/C and resident states Yes. Full lap tray reapplied. Asked resident if she wanted a snack or needed to go to the bathroom and she states No. No distress noted. [DATE] 12:40 a.m. Resident continues to sit in her W/C in hallway and continues to take Full lap tray off of her W/C. This nurse continues to redirect. Asked resident if she was tired and wanted to go to bed- she states No. [DATE] 12:45 a.m. Resident continues to sit in her W/C in hallway in Front of her Room. Resident continues to take her Full lap tray off of W/C and this nurse continues to put back on with her permission. Asked resident again if she was ready for bed, she states No. I told her I needed to step next door to another patient ' s room and I would be back in a minute or two. She states Okay. [DATE] 12:50 a.m. CNA reported that resident was on the Floor. When coming out of another patients Room and into Hallway resident was laying in the Floor Across the hall from her W/C lying face down with right side of her face against the floor. Small puddle of blood noted under her head. Small laceration noted to Right temple. After looking over her body-No other injuries noted. Log rolled her over to better evaluate her, did hear her moan and respond. [DATE] 01:00 a.m. Vital Signs (VS)= ,[DATE] - 98 - 79 - 20. Neurologic check done. Alert but drowsy, PERL (Pupils Equal, React to Light), Able to move extremities, when asked if she is having pain does not answer. Laceration to Right temple cleaned with Normal Saline (NS) and patted dry, steri strips applied and dry dressing applied. Transferred from Floor to W/C with assist of 2 people plus myself. Wheeled to bed and put back to bed to continue monitoring- 1:1 supervision initiated by this nurse. CNA at bedside with resident. [DATE] 01:15 a.m. Restless in bed. VS =,[DATE] - 98 - 79 - 20. Neurologic check done. Alert, Left Pupil reactive, Right Pupil not reactive. Able to move all extremities. Dressing to Right temple dry/intact. Pupils checked by 2nd nurse - Right side not reacting. (Physician) phoned and notified of fall with laceration to Right temple and that Left pupil reacting but Right pupil non-reactive. Orders received to send out to Hospital for Evaluation and treatment. Orders written. [DATE] 01:30 a.m. Called 911 for transport to Hospital after necessary paperwork copied and prepared. [DATE] 01:35 a.m. Ambulance and Emergency Medical Technician (EMT)/Paramedics here to pick up patient. All necessary paperwork given to them. History and report given to them. [DATE] 01:40 a.m. Patient left facility via stretcher with EMT personnel without incident going to Hospital by ambulance. [DATE] 01:42 a.m. Called Hospital emergency room (ER) and spoke to nurse and gave her report and history on patient. [DATE] 01:45 a.m. (Family) called and notified of fall with laceration to Right temple and patient was transferred to Hospital. [DATE] 01:47 a.m. Called Risk Manager to notify of patient fall received voicemail left message. [DATE] 04:10 a.m. (Family) called this Facility to let us know patient was admitted to Hospital and she was in Intensive Care Unit (ICU) with bleed in her brain . Review of a hospital record for [DATE] revealed that Resident # 3 was transferred by Air ambulance from the first hospital to a second hospital for neurosurgical evaluation and admission for critical care. Review of the Admission History and Physical in the emergency department for the second hospital for [DATE] revealed: The patient, an [AGE] year old Caucasian female, was sent here from (first hospital) for cerebral bleed. Patient has a subarachnoid hemorrhage on CT done at 0300 . She fell while sitting in a wheelchair at the nursing home (NH) with a laceration to the right supraorbital area and right upper eyelid. Physical examination, on [DATE], stated Neurologic - Intubated, sedated. Impression and Plan: admitted on [DATE] post fall from chair at NH, Found to have: SAH (Subarachnoid Hemorrhage) - on [MEDICATION NAME]. Review of the facility ' s physician's order [REDACTED]. According to www.PDR.net <http://www.PDR.net> (Physician ' s Desk Reference) [MEDICATION NAME] is an Antiplatelet agent and side effects include increased risk of bleeding. The brand name for [MEDICATION NAME] is [MEDICATION NAME]. Continued review of the hospital record indicated the patient was admitted to the Intensive Care Unit. Review of the Discharge Summary - Death Summary , dated [DATE] revealed: Hospital Course: [AGE] year old Caucasian female sent here from (name of first hospital) for cerebral bleed. The patient has a subarachnoid hemorrhage on CT done at 0300. Discussion with the patient ' s power of attorney noted that the patient is a do not resuscitate but would want surgical intervention if it could potentially help her and/or transfusion if necessary. She would not want Cardio [MEDICAL CONDITION] Resuscitation (CPR), electrical defibrillation or other resuscitative measures. The patient would want her Do Not Resuscitate (DNR) to stay in place. The patient arrived intubated and the power of attorney is aware of this. The patient is a former registered nurse with a history of dementia, incontinence of urine and has been at the nursing home about a year. She fell while sitting in a wheelchair at the nursing home. There was a laceration to the right supraorbital area and right upper eyelid. The nursing home staff had left then came back to find the patient on the ground with cut around the lateral area to the right eye. [DATE]: Sent from (first hospital) for SAH (Subarachnoid Hemorrhage) from fall out of wheelchair. CT head with contrast: several small to mod - sized foci of extra - axial hemorrhage, mainly in the sulci to frontal, parietal and temporal lobes, lacerations right supraorbital area and right upper eyelid closed in Emergency Department (ED) [DATE] Remains on mechanical vent but neuro is improving - failed SAT/SBT (Spontaneous Awakening Trial/Spontaneous Breathing Trial). [DATE] Daily SAT/SBT, patient does well on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) but not awake enough to protect airway. [DATE] Spoke with (family) and the plan is that family will most likely arrive in the next few days for eventual extubation with full DNR. If patient can awaken and protect her airway . fine, but if she cannot maintain off mechanical vent, then comfort care will be provided. [DATE] Patient becomes restless and coughs when sedation levels dropped but does not awaken/ follow commands. [DATE] No clinical change to suggest that patient can now protect airway. [DATE] On vent and not responsive and started Enteral tube feeds. [DATE] On vent and not fully alert and failed SBT. (Physician) discussed and explained to (family) about her medical problems, plan of care and prognosis. (Family) made a decision that they wanted to withdraw life support ventilator and stopped all her medications except comfort measures. She was extubated and on intravenous (IV) [MEDICATION NAME] and IV [MEDICATION NAME] and died in TICU. Family members at bedside. Preliminary cause of death listed (included but not limited to): Several small to moderate - sized foci of extra- axial hemorrhage. Hemorrhage mainly in the sulci of frontal lobes, parietal and temporal lobes. Therefore hemorrhage is likely mainly in the subarachnoid space. Most prominent foci of hemorrhage appears to be the frontal lobes and right temporal lobes after fall in nursing home from chair and she was on [MEDICATION NAME]. Acute Respiratory insufficiency, requiring mechanical ventilator and intubated on ,[DATE] and failure to wean off due to AMS (Altered Mental Status) and inability to protect airway . On [DATE] at 8:47 a.m. an interview was conducted with Staff A, the LPN who worked with Resident #3 on the 11 p.m. to 7 a.m. shift on [DATE] and wrote the nursing notes for [DATE] and [DATE]. She stated that when she came on shift for the 11:00 p.m. to 7:00 a.m. shift on [DATE]; Resident #3 was restless in the bed and not sleeping. Staff A stated they got her up in the wheelchair, put the lap tray on and brought her out in the hallway. Staff A stated she was afraid the resident would try to get up and was told not to leave her in her room alone; thus she brought her out in the hall to keep a close eye on her. Staff A stated she ' d been with someone by her side for so long. Staff A stated the resident kept taking the tray off, but never tried to get out of her chair. Staff A indicated that she and the aide would watch her and stated I had her close to the desk with me when (Staff B) went on break. Staff B brought her to me; I was doing paperwork at the desk. She stated that she had to go in to check on a resident in another room, and she parked her in front of her door, told her what I was doing and would be right back. She was parked facing the nurse ' s station at her room and I stepped into the room next door. She stated when Staff B came back to the floor after her break, she told her that Resident #3 was on the floor. Staff A stated I did not hear her get up or hear her go down. Staff A stated she had just gotten the blood pressure cuff on the other resident when she heard Staff B say the resident was on the floor. She stated, Her chair was by the door when I came out, she was lying diagonally in front of the wall across the hall . She stated the resident was face down with her head turned to the right and did not know how the resident got in that position. When asked if there were any other staff in the area when the resident fell she stated not that I know of. Staff A confirmed she came out to assess Resident #3 who was on the floor. She stated there was a little blood under her from the cut, superficial. She was crying a little bit. She stated that she and a Registered Nurse (RN/Staff C) checked the resident ' s vital signs and did neurologic checks. She stated the vital signs and neurologic checks were okay and between the two of us, felt comfortable, she only needed steri strips, no other injuries, she was crying. She stated they got her off the floor, placed her in her wheelchair and then in her bed and did neuro checks again. She stated, at that time, the neuro checks were abnormal; one pupil was not reacting, dilated and not responding . She stated she called the physician and received the order to send her to the hospital via 911. Staff A stated she had provided care for Resident #3 regularly on the 11 p.m. to 7 a.m. shifts. When asked to describe Resident # 3, she stated Some nights she was quiet and slept comfortably. Other times she was fidgety. Some nights she didn ' t sleep well, was fidgety and nervous when she was awake, we would put her in her chair, bring her out to the hall, let her socialize, give her a drink, magazines, then she would go back to sleep. An interview was held with Staff B, the CNA who provided care for Resident #3 on the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Staff B stated she had worked with Resident #3 since she came here and had provided 1:1 supervision to the resident in the past. She stated she was concerned that every 15 minute checks were not going to work for Resident #3. She stated Everyone knew it was going to be a problem. She stated, She was only every 15 minute checks, my main focus was on her. My first night having her off 1:1, I thought, this isn ' t going to work. I felt like I had to watch her every minute still. She stated she was climbing out of bed when I first came in that night. She was still the same, she had not gotten any better. When asked what the resident was like when she provided 1:1 supervision for her in the past, she stated She was restless, trying to get up, had to redirect her. Restless, tossing, turning, trying to get up, grabbing, and that she would bring her out of her room into the hall. Staff B stated when she came on shift, she does not recall if the resident was in bed. She stated when the resident was up in the hallway in her wheelchair, she stayed with her. She stated there was an activity tray on her wheelchair, she was trying to take it off, trying to get up, and she was very very busy when I was with her- I stayed with her. She stated that when she went on break, she told Staff A that she was going on break and brought Resident #3 to Staff A at the nurses ' station. She stated Q 15 minutes wasn ' t going to work, that it is why when I went on break I had her covered. Staff B stated when she returned from her break, she saw Resident # 3 on the floor. She stated no one was with her and she saw no staff in the hall. Staff B stated she alerted Staff A, who was in the patient ' s room next door. Staff B described Resident #3 as screaming, yelling and very agitated. She stated she asked her if she was hurt, then she saw the blood. She stated she does not know where the lap tray was, thinks it was off to the side somewhere. She stated Resident #3 was in the hallway outside of her door when she found her and Staff A was taking care of another patient in another room. An interview was held on [DATE] at 10:15 am with Staff C, the RN who assisted Staff A, after Resident #3 was found on the floor. During the interview, Staff C stated she was on another hall in Station 1 at the treatment cart with her back turned to the hall Resident #3 was on. Staff C was the RN supervisor on that shift and stated she heard someone say there she goes but did not know who that was. When asked to describe Resident #3 the night prior to the fall, Staff C stated She needed to be attended to, she still needed constant supervision because of impulsiveness and lack of understanding. Staff C stated that she and Staff A initially assessed the resident ' s vital signs and conducted neuro checks, looked for bleeding and bruising. She stated she (Resident #3) was making a strange sound, sort of a screeching, a different sound, a screeching sound . She stated that they placed her in her wheelchair, put her in her bed and started neuro checks again. She stated we knew she needed to go out because of her behavior and her right pupil started to be non - reactive. She was responsive, crying a little bit. On [DATE] at 6: 25 p.m. an interview was held with Staff D, an LPN who stated she provided care routinely for Resident #3 on the 3 p.m. to 11 p.m. shift. Staff D stated she was not working the day that Resident #3 fell . She stated, They had put her on 1: 1 for a long time, she was under our close watch and She tried to get up, that is why we kept a watch on her. Staff D stated, In the days before she fell , she was still trying to get up, so we had to watch her close. On [DATE] at 9:55 a.m. an interview was conducted with Staff E, a CNA who stated she had provided 1:1 supervision for Resident #3. Staff E described Resident #3 as In the beginning she was very restless, trying to jump up and we would have to redirect her. She would hear something in the hall, wanted to bake a cake. Toward the end, it wasn ' t as much but once in a while she would try and get up from her chair. A phone interview was conducted with Resident #3 ' s physician on [DATE] at approximately 8:20 a.m. The physician stated that the facility usually lets him know when they are going to increase or decrease the level of supervision for a resident, but he could not recall if he was informed of decreased supervision for Resident #3 and stated it was a long time ago. The physician stated Resident #3 was on 1:1 for almost the majority of the time since her admission to the facility, behavior had improved, and she no longer needed that particular supervision. He stated the family was notified of the change in the supervision. The physician stated the resident was able to be by herself without someone right with her, but unfortunately she fell . Review of documentation for Q 15 minute checks for Resident #3 for [DATE] revealed that from 9:30 a.m. to 8 p.m., the resident was noted to be at the Station 1 Nursing Station the majority of the time. At 8:15 p.m., she was noted to be in the bathroom and from 8:30 p.m. to 11 p.m., she was documented as being in bed. Documentation commencing from 11:15 p.m. to 11:30 p.m. revealed the resident ' s location was noted to be up in wheelchair (W/C). From 11:45 p.m. on [DATE] to 12:30 a.m. on [DATE], the resident ' s location was documented as W/C A Hall. At 12:45 a.m., Staff B, the Certified Nursing Assistant (C.N.A.) who provided care for this resident during the 11 p.m. to 7 a.m. shift on [DATE], had documented the resident ' s location as Floor. This was written over by Staff A, the Licensed Practical Nurse (LPN) who provided nursing care for the resident on [DATE] on the 11 p.m. to 7 a.m. shift. Employee A, wrote in wheelchair over Staff B ' s entry of Floor, and initialed the change. Documentation for 1:00 a.m. indicated the resident ' s location was Floor and at 1:15 a.m., the documentation indicated the resident ' s location was Floor. Record review for Resident # 3 revealed that she was admitted to the facility on [DATE]. Review of the Client [DIAGNOSES REDACTED]. Record review revealed Resident #3 sustained two falls in early 2015, [DATE] and [DATE]. The resident was placed on one to one supervision in [DATE] and remained on one to one supervision from [DATE] until approximately 10:00 a.m. on [DATE]. The resident had sustained no falls for a period of over 13 months while she received 1:1 supervision. Review of an annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a score of 3 (indicating Severe Cognitive Impairment) on the Brief Interview for Mental Status (BIMS) assessment. The resident was coded as needing extensive assistance of two persons for bed mobility and transfer, extensive assistance of one person for ambulation and total dependence for locomotion. Balance during transition and walking was coded as not steady, only able to stabilize with human assistance and the resident utilized a wheelchair for locomotion. Review of a Summary of Plan of Care , completed by a registered nurse on [DATE] revealed: Provide ½ side rails x 2 as enabler, geo mattress, w/c cushion, off load heels when in bed, provide 1: 1 increased observation 7 days/ week by facility staff due to impulsiveness /[MEDICAL CONDITION].Speech is clear but she appears confused and does not answer my questions appropriately . Requires 1: 1 supervision ,[DATE] due to impulsiveness and poor safety awareness. The Narrative summary includes Transfers with 1 person assist. Uses the w/c for mobility and it is propelled by staff. Review of Care plans for Resident #3 revealed a care plan, dated [DATE] and last reviewed [DATE] for a problem of risk for falls/injuries related to: [MEDICAL CONDITION], Decreased Activities of Daily Living (ADL ' s), Impaired Hearing, Impaired Memory, Impaired Vision, Unsteady Gait, and history of falls. Goals were listed as Will have as close to no falls possible by managing risk factors, if fall occurs, will have minimal injuries related to falls through next review. Fall risk Score 90 = High risk. Interventions included : Remind not to stand without assistance or use of assistive device if utilized; Use gait belt when helping to ambulate/transfer; Instruct/reinforce safety measures with ( resident )/ family such as transfer techniques, proper foot wear, locking wheelchair; Keep call light within reach; Encourage to ask for assistance as needed; Falling precautions program: if fall score is 25 or higher will use yellow wrist band; Monitor for changes in ADL ' s Cognition, Behavior, Mood and Medications for Potential Risk Factors; Staff will be responsive to individual hearing, vision or communication concerns (keep room and hallways free from hazardous objects/clutter, adequate lighting, reduction of background noise); Keep bed in lowest position to the floor when care is not being rendered and lock bed wheels at all times. A new care plan was written [DATE], when the resident was changed from 1: 1 supervision to every 15 minute checks, which listed a problem of Is in need of Q (every) 15 minute checks around the clock. Staff to resident assignment for closer supervision, monitoring and/or observation reference to but not limited to: impulsiveness at times. The goal was Will have no adverse outcomes/injuries through next review date. The interventions were not revised to reflect the change of level of supervision from 1:1 to Q 15 minute checks. Interventions still included The staff member assigned to the q 15 minutes around the clock checks will accompany the resident at all times (including bathing, showers, meals, toileting and off - unit activities). Resident will be within arm ' s reach at all times, even while sleeping; The staff member assigned to Q 15 minutes checks around the clock will not leave the resident at any time without a replacement staff member in place (breaks, meals, restroom, change of shift). The resident will not be left alone at any times; Staff member performing Q 15 minute around

Based on record review and interview, the facility failed to provide the services and oversight necessary to ensure safety & well-being for one (#2) of six residents reviewed for accidents & supervision, which resulted in a fall and subsequent death. The facility chose not to provide consistent one to one supervision for Resident #2, an [AGE] year old long term care resident with a [DIAGNOSES REDACTED]. Documentation in the nurse ' s notes demonstrated the resident ' s ongoing lack of safety awareness, restlessness, and the need for one to one supervision on six of fourteen nights (11:00 p.m. - 7:00 a.m. shift.). However, the facility neglected to provide additional staff for one to one supervision on the 11:00 p.m. - 7:00 a.m. for this vulnerable and confused resident whose son had placed her in the facility ' s hands with the expectations that his mother would be safe, secure and free from neglect. Subsequently, on [DATE] at 1:00 a.m., Resident #2 ambulated into the hall, unsupervised, and voided in the hallway. She then slipped in the urine and fell against the wall. Resident #2 died in the hallway where she fell . Based on observation, record and policy review, and interview, the facility also failed to provide necessary services needed to prevent neglect related to three occurrences of resident elopement, on [DATE] and [DATE], involving two (Residents #1 and 4) of six sampled residents which met the definition of elopement per the facility Elopement/Missing Resident policy. Resident #1 left the facility unwitnessed on [DATE], which the facility failed to identify as elopement and implement proactive measures to prevent future occurrences; on [DATE], both Resident #1 and Resident #4 left the facility, without escort, and unwitnessed by staff. The facility ' s failure to provide necessary goods and services to ensure the safety and well-being of residents resulted in findings of neglect which are on-going. Findings include: Record review for Resident #2 revealed she was admitted on [DATE], per the demographic sheet, with [DIAGNOSES REDACTED]. Review of the admission nurse ' s note, dated [DATE] at 11:15 a.m., provided that Resident #2 was "Alert with confusion and short term memory loss. Primary language is Spanish but able to understand some English...As told to us by her son she (Resident #2) doesn't know her own limitations and frequently gets up and down." Review of the Care Area Assessment, which is part of the Resident Assessment Instrument, dated [DATE], found that Resident #2 was admitted to the facility related to worsening of dementia and behaviors at home. Following admission, she continued to present with behaviors of disrobing in public. She was restless, getting up and down and not sleeping at night. She had to adjust to the separation from her son who was at her side almost 24 hours a day when she was at home. During review of the " Special Information and Consent for [MEDICAL CONDITION] Medication Use " form, dated [DATE], the following information was documented: Medication/Frequency: [MEDICATION NAME] 5mg by mouth daily. Reason for use of Drug: [MEDICAL CONDITION], restlessness. Non-[MEDICAL CONDITION] means attempted previously: 1:1, encouragement, cueing, quiet, calm surroundings. Review of the " Special Information and Consent for [MEDICAL CONDITION] Medication Use " form, dated [DATE] revealed: Medication/Frequency: [MEDICATION NAME] 25mg twice daily. Reason for use of Drug: [MEDICAL CONDITION], restlessness, agitation, compulsive behavior. Non-[MEDICAL CONDITION] means attempted previously 1:1, cues, and redirection. A review of the " Mood Interview for MDS (Minimum Data Set) 3.0 " form, dated [DATE], revealed the resident had difficulty falling asleep. Per question C, " Trouble falling or staying asleep or sleeping too much. " " Trouble falling asleep " was circled and coded (1) for " yes " for symptom Presence and (1) for " ,[DATE] days days-several days. " A review of the Minimum Date Set (MDS) with an Assessment Reference Date of [DATE] revealed the following information: Section C-Cognitive Pattern: Subsection C0300: Resident #2 was unable to recall the year, month, and day of the week and scored as " 0. " Section C-[MEDICAL CONDITION]: Subsection C1300: Resident #2 was inattentive and had disorganized thinking and coded as " 1 " (Behavior continuously present, dose not fluctuate). Section D-Mood: Subsection D0200: Symptom Presence and frequency -Feeling down, depressed, or hopeless (,[DATE] days), trouble falling or staying asleep, or sleeping too much (,[DATE] days), poor appetite or overeating (,[DATE] days),trouble concentrating on things such as reading a newspaper or watching television (,[DATE] days), moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. (,[DATE] days). Section E-Behavior: Subsection E0200: Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching staff, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident displayed this type of behaviors ,[DATE] days, but less than daily. Subsection E0500: Impact on resident: Put the resident at significant risk for physical illness or injury? Coded as (1) Yes. E0900: Has the resident wandered? Coded as (2) Occurred ,[DATE] days, but less than daily. E1000 Wandering impact: Does the wandering place the resident at a significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Coded as (2) Occurred ,[DATE] days, but less than daily. Does the wandering significantly intrude on the privacy or activities of others? Coded as (1) Occurred ,[DATE] days, but less than daily. Section G: Functional Status: Subsection G0110: Bed mobility, transfers, and eating were coded as ,[DATE] (limited assistance with one person), walk in room and corridor, dressing, toilet use, and personal hygiene were coded as ,[DATE] (extensive assistance with one person), locomotion on and off the unit was coded as ,[DATE] (supervision with set up). Subsection G0300 Balance during transitions and walking were coded as (2) not steady, only able to stabilize with staff assistance. Subsection: G0600 Mobility devices: resident uses a walker and a wheelchair. The following nurse ' s notes were found in the record: On [DATE] at 3:00 p.m., "Resident at nurse ' s station in wheelchair confused, looking for her son, attempting to stand up and run. After behavior was redirected she then proceeded in taking her clothes off again, behavior was redirected, she is now being propelled by staff around facility to divert her behavior. Safety maintained." On [DATE] at 12:15 a.m., "CNA is stationed outside of resident's room to better monitor resident." 2:00 a.m. "Resident placed in wheelchair because she wouldn't stay in bed and she was placed at the nurse's station. Resident would not stay seated. She would unlock the wheelchair wheels. Food was offered and accepted by resident. Resident continued to get up and then sit back down in wheelchair." 2:50 a.m. "Assigned CNA came and got resident. Resident is sitting with CNA while in wheelchair. One on one supervision for safety purposes." On [DATE] at 4:30 a.m., "Resident has remained awake all night. CNA has had to do constant monitoring of the resident." On [DATE] at 7:00 a.m. "Late entry from [DATE] 9:45 a.m., observed the resident sitting in the floor ... the floor was wet with urine ....denies pain and discomfort." 9:40 p.m. "....continues to need someone with her." On [DATE] at 7:30 a.m., "At 5:30 a.m. CNA reports resident sitting on CNAs backpack on the floor, resident spitting saliva in her hands and rubbing it in a circular motion on the floor. At 6:15 a.m. resident observed sitting on the day room floor, again, spitting saliva in hand and rubbing it in a circular motion on the floor the day room floor. " On [DATE] at 7:30 a.m., charting for 4:00 a.m. behaviors, "Around 4:00 a.m. the resident was observed ambulating in other resident's rooms and going through drawers. Resident observed urinating on the floor next to roommate ' s bed. Observed resident sitting on roommate ' s bed with roommate in it. Resident constantly taking off clothes and refuses to allow staff to put back on pants and nonskid socks. Redirected multiple times to maintain safety. Resident closely monitored by staff to maintain safety." On [DATE] at 4:20 a.m., "Several attempts were made to redirect her but resisted. Eventually the staff took turns watching her while we worked to complete our duties ... ... towards the end of the shift after last rounds the assigned CNA had to continuously keep watch on her. She sat in her room with her or she would ambulate her through the halls." On [DATE] at 4:10 a.m., "Observed in another resident's room ...resisting care .....staff attempting multiple times to put resident in wheelchair however resident refuses ....resident attempted to sit in window sill. Notified RN risk manager via telephone of behavior. Resident made 1:1. " On [DATE] at 9:00 p.m., "Resident continues on 1:1." On [DATE] at 1:00 a.m., "I (staff C) was walking into room [ROOM NUMBER] A .....I was in the doorway and looked to my right down the hall and saw Resident #2 slip. She had slipped in urine where she had voided right outside room [ROOM NUMBER]. She slipped backwards into the wall and was lying on her back with her head propped against the wall ... ....I ran to resident..... not responding to voice or touch...I called 911." An interview was conducted with the Risk Manager on [DATE] at 9:05 a.m. during the entrance conference. When she was asked if the facility had a policy regarding one to one (1:1) supervision and what the staff was supposed to do, she said, "We do not have a policy. We provide one to one supervision only as a 'Courtesy'. We do not get a Doctor's order." When questioned further, the risk manager said if the psychiatrist determines a resident to be a danger to self or others, he will order one to one supervision. The resident is kept on one to one supervision until the psychiatrist determines that it safe to discontinue the supervision. The risk manager said the floor nurses make the decision to place a resident on one to one supervision if a resident displays poor safety awareness. The floor nurse also determines when the one to one supervision is discontinued. A physician's orders [REDACTED]. When the Risk Manager was asked if there was a protocol for determining when the residents no longer need to have one to one supervision she said, "No." When asked if the nurse completes an assessment or documents the reasons why the resident no longer needs one to one supervision she said, "No." On [DATE] at 9:33 a.m., an interview was conducted with the Licensed Practical Nurse (LPN), Unit Manager (staff A). When asked why a resident would be placed one to one supervision she said, "If they are unsafe on their own; if they are capable of walking but not by themselves; if they are impulsive and need to be supervised at all times." When asked about the process for determining if a resident should be put on one to one supervision she said, "Normally we talk to the Social Worker, Risk Manager, and Director of Nurses; it is usually a combination of persons making the decision." When asked if the floor nurses make the decision to take a resident off supervision she said, " We could suggest; I do not think that it would be our decision. " When asked if the resident would be automatically taken off one to one at the end of a shift, she said, "We would not decide that at the end of the shift. It would be decided during the day with the team." On [DATE] at 11:18 a.m. an interview was conducted with the station one 7:00 a.m. - 3:00 p.m. shift LPN (staff B). She was asked to verify her signature on a nurse's noted dated [DATE] at 12:00 p.m. that read, "1:1 continues" she verified the signature as hers. When asked if she knew when the resident was placed on one to one supervision she said, "I would have to look at the physician's orders [REDACTED]." When asked the process of placing a resident on one to one supervision she said, "If there is a safety issue I would place a CNA with the resident." She confirmed she would then get a doctor's order. She said, the schedule was set to provide one to one supervision for Resident #2 on the 7:00 a.m. - 3:00 p.m. shift, but, she did not know about the other shifts. On [DATE] at 10:52 a.m., an interview was conducted with the LPN (staff C) responsible for Resident #2 on the night of her death. She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She stated Resident #2 was not on one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She said, "We have less staff as opposed to the day shift." When asked who determined that the resident didn't need to have one to one supervision from shift to shift she said, "The nurse." When asked if she decided Resident #2 did not need one to one supervision on the night shift the resident fell and subsequently died she said, "I did because the resident was in her bed with her eyes closed at the beginning of the shift." A review of the nurse ' s notes, dated [DATE] at 11:15 a.m. to [DATE] at 3:18 a.m., revealed the following information. The first documentation of one to one supervision was on [DATE] at 2:50 a.m. "One to one supervision for safety purposes." There was no documentation from [DATE]-[DATE] to indicate the resident was assessed and determined to be safe without one to one supervision on the 11:00 p.m.-7:00 a.m. shift. There was no documentation in the nurse ' s notes, additional assessments, or other documentation presented by the facility that indicated the one to one supervision was to be done only on the 3:00 p.m.-11:00 p.m. and 7:00 a.m.-3:00 p.m. shifts. There was continued documentation in the nurse ' s notes dated [DATE] at 2:50 a.m., [DATE] at 4:30 a.m., [DATE] at 2:00 a.m., and [DATE] at 7:30 a.m. regarding 4:00 a.m. behaviors. Also [DATE] at 4:20 a.m., and [DATE] at 4:10 a.m., clearly indicated the need for one to one supervision on the 11:00 p.m.-7:00 a.m. for Resident #2. A review of the "Daily Skilled Nurse's Note" with directions at the top of the page that read: "For each shift, check all applicable boxes" revealed the following information. On ,[DATE] and [DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern, " "wanders" and displayed "socially inappropriate behaviors." On [DATE] 11:00 p.m.-7:00 a.m., the nurse checked the box that indicated the resident was "restless." On [DATE]-[DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors" and was "restless." On [DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," and was "restless." On [DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors" and was "restless". On ,[DATE]-[DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." A review of the nurse staffing sheet, dated [DATE]-[DATE], revealed a staff member was assigned to provide one to one supervision on the following dates and shifts: [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m.. Per the assignment sheets the facility did not schedule one to one supervision on the 11:00 p.m.-7:00 a.m. shift during the entire shift, including the night of her death at 1:00 a.m. on [DATE]. Per the "Rehabilitation Department Care Plan," dated [DATE], Resident #2 required "extensive assistance of one person with functional mobility/functional transfers" and "extensive assistance of one person with ambulation/gait" secondary to [DIAGNOSES REDACTED]. Patient is also in a wheelchair now and not ambulating due to safety concerns." Per the "Summary of Plan of Care" dated [DATE], Care Plan #009 "Has 1:1 aide due to resident continuing to wander, enter other residents ' rooms, take her clothes off multiple times per day, play with light switches, and falling." Care plan #039, identified that the resident has a history of "being combative with son at home with history of not sleeping at home related to her progressing dementia." Per the Care Area Assessment (CAA) documentation note, dated [DATE], "She (Resident #2) is currently on 1:1 care due to mood/behavior issues." Per the plan of care narrative summary, dated [DATE], "She (Resident #2) has required 1:1 aide due to her severe confusion and dementia." On [DATE] at approximately 10:30 a.m., an interview was conducted via the telephone with the Certified Nurse ' s Assistant (CNA), (staff F) that was assigned to provide care for Resident #2 on the night of the resident ' s death. Staff (F) confirmed that she had worked during the 11:00 p.m. - 7:00 a.m. shift on [DATE] and confirmed she witnessed the event. She confirmed that Resident #2 was on her floor assignment which included the residents in rooms 172A through 180A. Staff (F) verified that her assignment did not include one to one supervision for Resident #2. Staff (F) revealed the following information regarding the occurrence involving Resident #2. She said she was coming out of a another resident ' s room making her rounds and saw Resident #2 a few doors down in the hallway. She said the resident urinated on the floor and as she walked toward the resident, the resident slipped, fell , and hit her head on the wall. When staff (F) was asked what the resident was doing earlier in the shift, she said around shift change (11:00 p.m.) the resident was walking around in her room and in the hallway. Staff (F) said she redirected the resident back to bed and did not see her again until the fall. Staff (F) verified that she had provided one to one supervision on the 3:00 p.m. - 11:00 p.m. shift on [DATE] but not on the 11:00 p.m.-7:00a.m. shift. When staff (F) was asked if she saw anyone providing one to one supervision on [DATE] during the 11:00 p.m.-7:00 a.m. shift, she said, " No I did not. " On [DATE] at 11:25 a.m., an interview via the telephone was conducted with the facility's Medical Director and physician for Resident #2. He said he knew the resident had advanced dementia and a history of aggression. He said the facility notified him that the resident was continuing to have agitation. He ordered a psychiatric consult and increased the [MEDICATION NAME]. He did not recall if he had been notified of the resident's need for continued one to one supervision. On [DATE] at 4:37 p.m., a second interview was conducted via the telephone with the Medical Director and physician for Resident #2. He confirmed that he was aware of her death. He did not remember if he had been notified that the resident was on one to one supervision. When asked if it was important for him to be notified if the resident was on one to one supervision but such supervision was not being provided. He said " Yes. It is important. I would want to know. " On [DATE] at 2:40 p.m. during an interview with the Risk Manager (RM) the following information was revealed. When asked what the process was for implementing one to one supervision, the Risk Manager said if the psychiatrist determines that a resident is not safe, he will order the resident to be one to one supervision and the resident will stay on such until the psychiatrist decides that the resident is safe with the increased supervision. If the resident is determined to be safe without one to one supervision the resident is then put on the standard every two hours rounds. The psychiatrist is the only one who can decide whether or not the resident no longer needs one to one supervision. When asked if the psychiatrist is not involved in placing a resident on one to one supervision such as the case with Resident #2 she said, " The nurse assesses the situation if she feels that the resident needs additional supervision she will call the Director of Nurses, Assistant Director of Nurses, or the Risk Manager. They will let us know what is going on and we will put someone with them. " When asked if the nurses should be documenting the call the RM said, " It is not written anywhere that they have to, it is at the nurse ' s discretion. " When asked if there was a formal process for discontinuing one to one supervision she said, " No there is not, only when a doctor has ordered a one to one, he has to come in to assess and he writes a discontinuation order. What happens is: the oncoming nurse looks at the situation, she looks and determines that a one to one comes off due to non-exhibiting of behaviors. " When asked, if there should be documentation of the absence of behaviors she said, " There should be. I as a nurse would document, resident no longer exhibiting behaviors. " When asked if she would specifically document the removal of the one to one, she said they have " not been instructed to document the removal of the one to one. " When asked if the physician is notified when a resident is placed on one to one supervision, she said " No, it is a nursing measure. " When asked if the physician is notified when the resident is removed from 1:1 supervision she said, " No. " On [DATE] at 6:20 p.m. an interview was conducted with the Administrator. He said he was aware that Resident #2 was on 1:1 supervision on two shifts. He said he was aware that the facility did not have one to one supervision on the night shift because he understood the resident slept during the night. The Administrator said the facility is the process of training all employees and implementing the new policy related to 1:1 supervision. He said he is and will continue to have total involvement to ensure the process is complete. In addition, all the information will be brought to the Quality Assurance meeting and reviewed by the physician and Quality Assurance team. A time line of events at the time and after the death of Resident #2 was provided by the Risk Manager and dated [DATE] with the following information. At 1:15 a.m. on [DATE], the Risk Manager was informed that Resident #2 " had fallen, was unresponsive and 911 had been called. " The Risk Manager arrived at the facility at approximately 2:37 a.m. Three police officers were standing at the nurse ' s station. The Risk Manager told the officers that she had to report the death to the Medical Examiner (ME) per the " Florida Guidelines for Long Term Care." The Risk Manager explained that the ME had to be called because the resident died after a fall. The Risk Manager informed the officers that she had to assess the resident and one of the officers went with her to the resident in the hallway. Resident #2 ' s son was present at this time. The Risk Manager assessed the resident and found no bruising, lacerations, or discoloration to the front of her head. The back of the head was " intact and free of injury. " A head to toe assessment revealed no injury, redness, swelling, or bruising. The resident had on " wet underwear, a gown and nothing on her feet. " At approximately 2:45 a.m. the Medical Examiner called and asked what the police had determined and if the resident ' s physician would sign the death certificate. The RM told the ME what the police had determined and that the resident ' s physician would sign the death certificate. The funeral home arrived at 3:18 a.m. to receive the resident. The son for Resident #2 was present and left the facility with the funeral attendant and his mother. 2. An interview was conducted on [DATE] at approximately 10:30 a.m. with the Risk Manager, who stated that the facility uses Roam Alerts for residents who wander. It is a band on the ankle, or if we have a wheel chair bound person, it will be on the w/c. When asked if the facility had a policy regarding supervision and what staff was supposed to do, the RM stated: " 1:1, we do it as courtesy. " She further stated: " do not think we have a policy " (about supervision.) During the interview conducted on [DATE] at approximately 10:30 a.m. with the Administrator, he stated the entire building is locked, except for the front (door) that is open from around 7:00 a.m. to 8:00 p.m. He stated that the wander guard locks the door. Beyond the open time, we use the key pad. In an interview conducted on [DATE] at approximately 2:00 p.m. with the Maintenance Director, he stated that he had been in his position for approximately 7.5 years that he normally worked from 6:30 a.m. until 3:00 p.m. and for the weekend coverage, the staff calls either him or two of the other maintenance persons. The Maintenance Director stated that last year around ,[DATE] we had (the)Roam Alert ; these go on a band around the ankle, if they come within 12 and 15 feet of the door, the door will lock; this is how it would work on all the doors. He further stated that, " Then we switched over; we wanted the back doors locked all times; 4 (back) doors. " About a month ago, we got service from (a local technology company). " The Maintenance Director provided a bill, dated [DATE] for 2,529.47; Invoice #,[DATE], final billing for key pads, cable/wire, labor, etc.). The Maintenance Director stated this was for new key pads/ replacement keypads that he recommended (during the switch over). He further stated: " To get in the back door, you have to put the code in and out. Better off having them (the doors) locked at night; transient people walk by. " (The) Front lobby, locks automatically at 8pm and unlocks automatically at 7am. (We) Still use the roam lock. " " We had some wiring problems; I think that residents would go out with another person. " " I think that it is working well, whatever time that the (local technology company) came, it has been working; we test every day; we do not document. " At approximately 2:10 p.m. on [DATE], the Maintenance director and the surveyor walked around the building to review the exit doors. The facility had a front door and 4 additional (rear) exit doors, 3 doors were at the end of residential halls and 1 door was near an activity room located by the kitchen. The function of the doors was reviewed with a sample Roam Alert band. The 4 (rear) doors were observed to be locked. The door was observed to have the ability to open, when a code was pressed into the key pad located in the proximity of the door. The front door of the facility was observed to open readily when pushed upon when the Roam Alert band was outside of an approximate 12 foot range; when the roam alert band was within a closer range of 12 feet to the front door, the door locked. Signage was observed on all 5 doors that stated the following: " Please make sure residents DO NOT exit as you enter Thank you. " A review of Resident #1 's Nurses' Notes, dated [DATE] at 7:00 p.m. reflected: "Resident was seen outside front door at the porch area around 6:40 p.m. Brought back into the building. No apparent injuries observed. Easily re-directed. Responsible party notified. Dr. aware of incident, 1:1 service given this shift. " A review of Resident #1 ' s clinical chart for the period from [DATE] through [DATE] found Physician orders [REDACTED]." A review of the facility event log, documented that on [DATE] at 6:40 p.m.: " Visitor reported that resident was outside on the front porch with only socks on staff found resident standing in front of porch area easily redirected to building. " The event was documented not to be an elopement event or an event which required reporting to the State Agency, even though it met the definition of an elopement by the facility standards, and reflected the omission of services to maintain safety of the resident. A second, unescorted facility exit by Resident #1, less than two months later, was portrayed in the following staff note: Resident #1 's Nurses notes, dated [DATE] at 10:50 a.m. found a late entry which reflected that " on [DATE] around 11:50 a.m., resident (#1) noted by dumpster by staff, staff assisted resident back into facility; no apparent injuries noted. MD, family notified, will continue to monitor resident. " An interview conducted on [DATE] at 3:00 p.m. with the Risk Manager (RM), who confirmed that the process followed by the facility for an event was for the staff to complete a form which described the event, and subsequently this form was reviewed by her and other members of management. For the event that occurred on [DATE], the RM, confirmed that a Licensed Practical Nurse (LPN) had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM further stated that it was a family member of another resident that had brought to their attention that Resident #1 had exited the front door during their entrance/exit to the facility while they were bringing items into the facility. The RM confirmed that staff had not witnessed Resident #1 exit the building. For the event that occurred on [DATE], the RM, she confirmed that a LPN had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM confirmed that the staff member who saw Resident outside by the dumpster did not see the actual exit from the door by the resident. A review of Resident #1 ' s clinical chart, documented that resident originally admitted to the facility [DATE] with a readmission on [DATE]. The resident was [AGE] years old. The record of admission listed [DIAGNOSES REDACTED]. A review of Resident #1 ' s Care Plan, dated [DATE], reprinted [DATE], and updated on [DATE] documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place secure care monitoring device on Resident #1 and t

Based on record review and interview the facility failed to thoroughly investigate a death after a fall and failed to immediately report the findings of the investigation as mandated by Federal regulations for one (#2) of six residents. Resident #2, an [AGE] year old woman, was assessed to require one to one supervision; extensive assistance of one person with functional mobility/functional transfers; extensive assistance of one person with ambulation/gait secondary to a [DIAGNOSES REDACTED]. . Based on observation, record review, and interviews, the facility also failed to report to the State Agency three occurrences of resident elopement, on [DATE] and [DATE], involving two (Residents #1 and 4) of six sampled residents, resulting from the omission of oversight needed to ensure their safety and well-being. The occurrences met the definition of elopement per the facility Elopement/Missing Resident policy. Resident #1 left the facility, unwitnessed on [DATE], which the facility failed to identify as elopement and implement proactive measures to prevent future unsupervised departures. On [DATE], both Resident #1 and Resident #4 left the facility, without escort, and unwitnessed by staff. The facility practices resulted in findings of immediate jeopardy which is on-going. Findings: 1. A time line, dated [DATE], of events at the time of and after the death of Resident #2 was provided by the Risk Manager during an interview on [DATE], at 4:00 p.m., : "At 1:15 a.m. on [DATE], the Risk Manager was informed that Resident #2 " had fallen, was unresponsive and 911 had been called. " The Risk Manager arrived at the facility at approximately 2:37 a.m. Three police officers were standing at the nurse ' s station. The Risk Manager told the officers that she had to report the death to the Medical Examiner (ME) per the " Florida Guidelines for Long Term Care. " The Risk Manager explained that the ME had to be called because the resident died after a fall. The Risk Manager informed the officers that she had to assess the resident and one of the officers went with her to the resident in the hallway. Resident #2 ' s son was present at this time. The Risk Manager assessed the resident and found no bruising, lacerations, or discoloration to the front of her head. The back of the head was " intact and free of injury. " A head to toe assessment revealed no injury, redness, swelling, or bruising. The resident had on " wet underwear, a gown and nothing on her feet." At approximately 2:45 a.m. the Medical Examiner called and asked what the police had determined and if the resident ' s physician would sign the death certificate. The RM told the ME what the police had determined and that the resident ' s physician would sign the death certificate. The funeral home arrived at 3:18 a.m. to receive the resident. The son for Resident #2 was present and left the facility with the funeral attendant and his mother. A record review for Resident #2 revealed she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nurse ' s notes for Resident #2 from ,[DATE]-[DATE] revealed an admission nurse ' s note dated [DATE], at 11:15 a.m., which stated the resident was "Alert with confusion and short term memory loss. Primary language is Spanish but able to understand some English...As told to us by her son she (Resident #2) doesn't know her own limitations and frequently gets up and down." The following nurse ' s notes were also found in the record: On [DATE] at 300 p.m., "Resident at nurse ' s station in wheelchair confused, looking for her son, attempting to stand up and run. After behavior was redirected she then proceeded in taking her clothes off again behavior was redirected, she is now being propelled by staff around facility to divert her behavior. Safety maintained." On [DATE] at 1215 a.m., "CNA is stationed outside of resident's room to better monitor resident." 2:00 a.m. "Resident placed in wheelchair because she wouldn't stay in bed and she was placed at the nurse's station. Resident would not stay seated. She would unlock the wheelchair wheels. Food was offered and accepted by resident. Resident continued to get up and then sit back down in wheelchair." 2:50 a.m. "Assigned CNA came and got resident. Resident is sitting with CNA while in wheelchair. One on one supervision for safety purposes." On [DATE] at 4:30 a.m., "Resident has remained awake all night. CNA has had to do constant monitoring of the resident." On [DATE] at 7:00 a.m. "Late entry from [DATE] 945 a.m., observed the resident sitting in the floor ... the floor was wet with urine ....denies pain and discomfort." 9:40 p.m. "....continues to need someone with her. " On [DATE] at 730 a.m., "At 5:30 a.m. CNA reports resident sitting on CNAs backpack on the floor, resident spitting saliva in her hands and rubbing it in a circular motion on the floor. At 6:15 a.m. resident observed sitting on the day room floor again spitting saliva in hand and rubbing it in a circular motion on the floor the day room floor. " On [DATE] at 3:00 p.m., "Safety maintained. Will continue to monitor, 1:1 continues for safety." On [DATE] at 7:30 a.m., charting for 4:00 a.m. behaviors, "Around 4:00 a.m. the resident was observed ambulating in other resident's rooms and going through drawers. Resident observed urinating on the floor next to roommate ' s bed. Observed resident sitting on roommate ' s bed with roommate in it. Resident constantly taking off clothes and refuses to allow staff to put back on pants and nonskid socks. Redirected multiple times to maintain safety. Resident closely monitored by staff to maintain safety." On [DATE] at 3:00 p.m., "1:1 continues. Resident restless, agitated." On [DATE] at 4:20 a.m., "Several attempts were made to redirect her but resisted. Eventually the staff took turns watching her while we worked to complete our duties ... ... towards the end of the shift after last rounds the assigned CNA had to continuously keep watch on her. She sat in her room with her or she would ambulate her through the halls." On [DATE] at 4:10 a.m., "Observed in another resident's room ...resisting care .....staff attempting multiple times to put resident in wheelchair however resident refuses ....resident attempted to sit in window sill. Notified RN Risk Manager via telephone of behavior. Resident made 1:1. " On [DATE] at 12:00 p.m., "1:1 continues .....MD in to see resident. New orders received to increase [MEDICATION NAME] to 50 mg PO BID ...son notified.....safety maintained. " On [DATE] at 9:00 p.m., "Resident continues on 1:1." On [DATE] at 1:00 a.m., "I (staff C) was walking into room [ROOM NUMBER] A .....I was in the doorway and looked to my right down the hall and saw Resident #2 slip. She had slipped in urine where she had voided right outside room [ROOM NUMBER]. She slipped backwards into the wall and was lying on her back with her head propped against the wall ... ....I ran to resident..... not responding to voice or touch...I called 911." An interview was conducted with the Risk Manager on [DATE] at 9:05 a.m. during the entrance conference. When she was asked if the facility had a policy regarding one to one supervision and what the staff were supposed to do she said, "We do not have a policy. We provide one to one supervision only as a 'Courtesy'. We do not get a Doctor's order." When questioned further, the Risk Manager said if the psychiatrist determines a resident to be a danger to self or others he will order one to one supervision. The resident is kept on one to one supervision until the psychiatrist determines that it safe to discontinue the supervision. The Risk Manager said the floor nurses make the decision to place a resident on one to one supervision if a resident displays poor safety awareness. The floor nurse also determines when the one to one supervision is discontinued. A physician's orders [REDACTED]. When the Risk Manager was asked if there is a protocol for determining when the residents no longer need to have one to one supervision she said, "No." When asked if the nurse completes an assessment or documents the reasons why the resident no longer needs one to one supervision she said, "No." On [DATE] at 9:33 a.m. an interview was conducted with the Licensed Practical Nurse (LPN), Unit Manager (staff A). When asked why a resident would be placed one to one supervision she said, "If they are unsafe on their own; if they are capable of walking but not by themselves; if they are impulsive and need to be supervised at all times." When asked about the process for determining if a resident should be put on one to one supervision she said "Normally we talk to the Social Worker, Risk Manager, and Director of Nurses; it is usually a combination of person ' s making the decision." When asked if the floor nurses make the decision to take a resident off supervision she said, " We could suggest; I do not think that it would be our decision. " When asked if the resident would be automatically taken off one to one at the end of a shift, she said, "We would not decide that at the end of the shift. It would be decided during the day with the team." On [DATE] at 11:18 a.m. an interview was conducted with the station one 7:00 a.m. - 3:00 p.m. shift LPN (staff B). She was asked to verify her signature on a nurse's noted dated [DATE] at 12:00 p.m. that read, "1:1 continues" she verified the signature as hers. When asked if she knew when the resident was placed on one to one supervision she said, "I would have to look at the physician's orders [REDACTED]." When asked the process of placing a resident on one to one supervision she said, "If there is a safety issue I would place a CNA with the resident." She confirmed she would then get a doctor's order. She said, the schedule was set to provide one to one supervision for Resident #2 on the 7:00 a.m. - 3:00 p.m. shift but did not know about the other shifts. On [DATE] at 10:52 a.m. an interview was conducted with the LPN (staff C) responsible for Resident #2 on the night of her death. She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She said, "We have less staff as opposed to the day shift." When asked who determined that the resident didn't need to have one to one supervision from shift to shift she said, "The nurse." When asked if she decided Resident #2 did not need one to one supervision on the night the resident fell and subsequently died she said, "I did because the resident was in her bed with her eyes closed at the beginning of the shift." On [DATE] at approximately 10:30 a.m. an interview was conducted via the telephone with the Certified Nurse ' s Assistant (CNA), (staff F) that was assigned to provide care for Resident #2 on the night of the resident ' s death. Staff (F) confirmed that she had worked during the 11:00 p.m. - 7:00 a.m. shift on [DATE] and confirmed she witnessed the event. She confirmed that Resident #2 was on her floor assignment which included the residents in rooms 172A through 180A. Staff (F) verified that her assignment did not include one to one supervision for Resident #2. Staff (F) revealed the following information regarding the occurrence involving Resident #2. She said she was coming out of a another resident 's room making her rounds and saw Resident #2 a few doors down in the hallway. She said the resident urinated on the floor and as she walked toward the resident, the resident slipped, fell , and hit her head on the wall. When staff (F) was asked what the resident was doing earlier in the shift, she said around shift change (11:00 p.m.) the resident was walking around in her room and in the hallway. Staff (F) said she redirected the resident back to bed and did not see her again until the fall. Staff (F) verified that she had provided one to one supervision on the 3:00 p.m. - 11:00 p.m. shift on [DATE] but not on the 11:00 p.m.-7:00 a.m. shift. When staff (F) was asked if she saw anyone providing one to one supervision on [DATE] during the 11:00 p.m.-7:00a.m. shift, she said, " No I did not. " A review of the nurse ' s notes dated [DATE] at 11:15 a.m. - [DATE] at 3:18 a.m. revealed the following information. The first documentation of "one to one supervision" was [DATE] at 2:50 a.m. "One to one supervision for safety purposes." There was no documentation from [DATE]-[DATE] to indicate the resident was assessed and determined to be safe without one to one supervision on the 11:00 p.m.-7:00 a.m. shift. There was no documentation in the nurse ' s notes, additional assessments, or documentation presented by the facility that indicated the one to one supervision was to be done only on the 3:00 p.m.-11:00 p.m. and 7:00 a.m.-3:00 p.m. shifts. There was continued documentation in the nurses notes dated [DATE] at 2:50 a.m., [DATE] at 4:30 a.m., [DATE] at 2:00 a.m., [DATE] at 7:30 a.m. (regarding 4:00 a.m. behaviors), [DATE] at 4:20 a.m., and [DATE] at 4:10 a.m., that indicated the need for one to one supervision on the 11:00 p.m.-7:00 a.m. for Resident #2. A review of the "Daily Skilled Nurse's Note" with directions at the top of the page that read: "For each shift, check all applicable boxes" revealed the following information. On ,[DATE] and [DATE] for 11:00 p.m.-7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern, "wanders" and displayed "socially inappropriate behaviors." On [DATE] 11:00 p.m.-7:00 a.m. the nurse checked the box that indicated the resident was "restless." On [DATE]-[DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On [DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," and was "restless." On [DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On ,[DATE]-[DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." A review of the nurse staffing sheet dated [DATE]-[DATE] revealed a staff member was assigned to provide one to one supervision on the following dates and shifts: [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 is p.m.-11:00 p.m. Per the assignment sheets the facility did not schedule one to one supervision on the 11:00 p.m.-7:00 a.m. during the resident's entire stay including the night of her death at 1:00 a.m. on [DATE]. Per the "Rehabilitation Department Care Plan," dated [DATE], Resident #2 required "extensive assistance of one person with functional mobility/functional transfers" and "extensive assistance of one person with ambulation/gait" secondary to [DIAGNOSES REDACTED]. Patient is also in a wheelchair now and not ambulating due to safety concerns." Per the "Summary of Plan of Care" dated [DATE], Care Plan #009 "Has 1:1 aide due to resident continuing to wander, enter other residents ' rooms, take her clothes off multiple times per day, play with light switches, and falling." Care plan #039 reflected the resident had a history of [REDACTED]." Per the Care Area Assessment (CAA) documentation note, dated [DATE], "She (Resident #2) is currently on 1:1 care due to mood/behavior issues." Per the plan of care narrative summary, dated [DATE], "She (Resident #2) has required 1:1 aide due to her severe confusion and dementia." A review of the Minimum Data Sheet (MDS) with an Assessment Reference Date of [DATE] revealed the following information: Section C-Cognitive Pattern: Subsection C0300: Resident #2 was unable to recall the year, month, and day of the week and scored as " 0 " . Section C-[MEDICAL CONDITION]: Subsection C1300: Resident #2 was inattentive and had disorganized thinking and coded as " 1 " (Behavior continuously present, does not fluctuate. Section D-Mood: Subsection D0200: Symptom Presence and frequency -Feeling down, depressed, or hopeless (,[DATE] days), trouble falling or staying asleep, or sleeping too much (,[DATE] days), poor appetite or overeating (,[DATE] days),trouble concentrating on things such as reading a newspaper or watching television (,[DATE] days), moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. (,[DATE] days). Section E-Behavior: Subsection E0200: Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching staff, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident displayed this type of behaviors ,[DATE] days, but less than daily. Subsection E0500: Impact on resident: Put the resident at significant risk for physical illness or injury? Coded as (1) Yes. E0900: Has the resident wandered? Coded as (2) Occurred ,[DATE] days, but less than daily. E1000 Wandering impact: Does the wandering place the resident at a significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Coded as (2) Occurred ,[DATE] days, but less than daily. Does the wandering significantly intrude on the privacy or activities of others? Coded as (1) Occurred ,[DATE] days, but less than daily. Section G: Functional Status: Subsection G0110: Bed mobility, transfers, and eating were coded as ,[DATE] (limited assistance with one person), walk in room and corridor, dressing, toilet use, and personal hygiene were coded as ,[DATE] (extensive assistance with one person), locomotion on and off the unit was coded as ,[DATE] (supervision with set up). Subsection G0300 Balance during transitions and walking were coded as (2) not steady, only able to stabilize with staff assistance. Subsection: G0600 Mobility devices: resident uses a walker and a wheelchair On [DATE] at 11:25 a.m., an interview via the telephone was conducted with the facility's Medical Director and physician for Resident #2. He said he knew the resident had advanced dementia and a history of aggression. He said the facility notified him that the resident was continuing to have agitation. He ordered a psychiatric consult and increased the [MEDICATION NAME]. He did not recall if he had been notified of the resident's need for continued one to one supervision. On [DATE] at 4:37 p.m., a second interview was conducted via the telephone with the Medical Director and physician for Resident #2. He confirmed that he was aware of her death. He did not remember if he had been notified that the resident was on one to one supervision. When asked if it was important for him to be notified if the resident was on one to one supervision, but, such supervision was not being provided. He said " Yes. It is important. I would want to know. " On [DATE] at 2:40 p.m. during an interview with the Risk Manager (RM) the following information was revealed. When asked what the process was for implementing one to one supervision the Risk Manager said, if the psychiatrist determined that a resident was not safe, he would order the resident to be one to one supervision and the resident would stay on such until the psychiatrist decided the resident was safe with the increased supervision. If the resident was determined to be safe without one to one supervision the resident was then put on the standard every two hours rounds. The psychiatrist was the only one who could decide whether or not the resident no longer needed one to one supervision. When asked if the psychiatrist is not involved in placing a resident on one to one supervision such as the case with Resident #2 she said, " The nurse assesses the situation if she feels that the resident needs additional supervision she will call the Director of Nurses, Assistant Director of Nurses, or the Risk Manager. They will let us know what is going on and we will put someone with them. " When asked if the nurses should be documenting the call the RM said, " It is not written anywhere that they have to, it is at the nurse ' s discretion. " When asked if there was a formal process for discontinuing one to one supervision she said, " No there is not, only when a doctor has ordered a one to one , he has to come in to assess and he writes a discontinuation order. What happens is: the oncoming nurse looks at the situation, she looks and determines that a one to one comes off due to non-exhibiting of behaviors. " When asked, if there should be documentation of the absence of behaviors she said, " There should be. I as a nurse would document, resident no longer exhibiting behaviors. " When asked if she would specifically document the removal of the one to one, she said, " They have not been instructed to document the removal of the one to one. " When asked if the physician was notified when a resident was placed on one to one supervision, she said " No it is a nursing measure. " When asked if the physician was notified when the resident is removed from 1:1 supervision she said, " No. " On [DATE] at approximately 4:00 p.m. an interview was conducted with the Risk Manager. When asked if she had conducted an investigation related to Resident #2, she said " Yes. I came into the building and started my investigation immediately. " Per the narrative time line of the events given to this surveyor by the Risk Manager dated [DATE], " at 11:15 p.m.-11:30 p.m. Resident #2 was taken to the bathroom by her Certified Nurse ' s Assistant (CNA). She was returned to bed and had non-skid socks placed back on her feet. At 1:00 a.m. the resident was seen in the hallway outside her room near the fire doors. She had urinated on the floor and was noted to have fallen. Staff attempted to reach her however could not in time to prevent the fall. Emergency Medical Services (EMS) called and subsequently the resident expired at 1:30 a.m. " The Risk Manager was asked if she filed an immediate and 5 day report as mandated, she said " No it was not abuse. " She did not say anything about neglect. When asked if she was going to file a 15 day adverse report she said, " I don ' t know. I ' m going to wait to see what you all (referring to the survey team) find. " On [DATE] at 6:20 p.m. an interview was conducted with the administrator. He said he was aware that Resident #2 was on 1:1 supervision on two shifts. He said he was aware that the facility did not have one to one supervision on the night shift because he understood the resident slept during the night. The administrator said the facility is the process of training all employees and implementing the new policy related to 1:1 supervision. He said he is and will continue to have total involvement to ensure the process is complete. In addition, all the information will be brought to the Quality Assurance meeting and reviewed by the physician and Quality Assurance team. 2. A review of the facility event log for ,[DATE] revealed an entry: [DATE], Resident #4, elopement. The log documented that the event occurred on [DATE] at 11:00 a.m.: " Resident noted to be outside and returned to building without injury. He was outside approximately 5 minutes. He exited the front door after he and a friend ... " A review of a documented timeline, dated [DATE], for Resident #4, referenced the elopement event that occurred on [DATE] and included the following: On Monday, [DATE] at 11:30 a.m., I was notified by the unit manager on station 1 that Resident #4 had been found outside of the facility on the back side of the building by staff and returned without incident. The resident did have a Roam alert alarm on and all doors were locking correctly. In addition, the timeline documented an interview with a housekeeper, Staff Member G, who observed the resident outside: " I was outside at the picnic table when I look up and see the man walking next to the building. I know this was not right, so I walk up to him and say Hi. I asked him what he was doing and he said he was looking for his car but no could find it. He started walking away from me and I said I go with him and he was like no he can do it on his own. So I did not want him to go so I said do you know me what my name is and he said he knew me. I told him his car was up in the front parking and he said oh no and I say oh yes and I started him back to the door by the time clock and walked him in .... " The timeline for the [DATE] event for Resident #4 had no documentation of a staff member witnessing Resident #4 ' s unauthorized exit from the facility into unauthorized areas outside of the building. An observation conducted on [DATE] at approximately 11:20 a.m., revealed Resident #1 walking down the hall. She was dressed for the day appropriately. She did not have shoes on, but, wore nonskid socks. Resident #1 approached the counter, looked at Staff Member E, looked at the surveyor and then walked away. Staff member E was observed to try to offer Resident #1 a cookie from the snack tray; however, the resident had walked away. The nurse followed and gave the cookie to the resident. A review of Resident #1 ' s clinical chart, documented that resident originally admitted to the facility [DATE] with a readmission on [DATE]. The resident was a [AGE] years old. The record of admission listed [DIAGNOSES REDACTED]. An interview was conducted on [DATE] at approximately 11:15 a.m. with Staff Member E, a Licensed Practical Nurse. She stated that Resident #1 walked around the building a lot; " she is ambulatory, a quick walker; she walks, walks, walks, she doesn ' t talk to but a few people. " A review of Resident #1 ' s Nurses ' Notes, dated [DATE] at 7:00 p.m. reflected: " Resident was seen outside front door at the porch area around 6:40 p.m. Brought back into the building. No apparent injuries observed. Easily re-directed. Responsible party notified. Dr. aware of incident, 1:1 service given this shift. " A review of Resident #1 ' s clinical chart for the period from [DATE] through [DATE] found Physician orders [REDACTED]. " A review of the facility event log, documented that on [DATE] at 6:40 p.m.: " Visitor reported that resident was outside on the front porch with only socks on staff found resident standing in front of porch area easily redirected to building. " The event was documented not to be an elopement event or an event which is required to be reported to the State Agency, even though it met the definition of an elopement by the facility standards. Further review of Resident #1 ' s Nurses notes, dated [DATE] at 10:50 a.m. found a late entry which reflected that " on [DATE] around 11:50 a.m., resident (#1) noted by dumpster by staff, staff assisted resident back into facility; no apparent injuries noted. MD, family notified, will continue to monitor resident. " An interview conducted on [DATE] at 3:00 p.m. with the Risk Manager (RM), who confirmed that the process followed by the facility for an event was for the staff to complete a form which described the event, and subsequently this form was reviewed by her and other members of management. For the event that occurred on [DATE], the RM, confirmed that a Licensed Practical Nurse (LPN) had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM further stated that it was a family member of another resident that had brought to their attention that Resident #1 had exited the front door during their entrance/exit to the facility while they were bringing items into the facility. The RM confirmed that staff had not witnessed Resident #1 exit the building. For the event that occurred on [DATE], the RM, she confirmed that a LPN had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM confirmed that the staff member who saw Resident outside by the dumpster did not see the actual exit from the door by the resident. An interview was conducted on [DATE] at approximately 10:30 a.m. with the Risk Manager, who stated that the facility uses Roam Alerts. It is a band on the ankle, or if we have a wheel chair bound person, it will be on the w/c. When asked if the facility had a policy regarding supervision and what staff was supposed to do, the RM stated: " 1:1, we do it as courtesy. " She further stated: " do not think we have a policy " (about supervision.) During the interview conducted on [DATE] at approximately 10:30 a.m. with the Administrator, he stated the entire building is locked, except for the front (door) that is open from around 7:00 a.m. to 8:00 p.m. He stated that the wander guard locks the door. Beyond the open time, we use the key pad. In an interview conducted on [DATE] at approximately 2:00 p.m. with the Maintenance Director, he stated that he had been in his position for approximately 7.5 years, which he normally worked from 6:30 a.m. until 3:00 p.m., and for the weekend coverage, the staff calls either him or two of the other maintenance persons. The Maintenance Director stated: Last year around ,[DATE] we had (the)Roam Alert ; these go on a band around the ankle, if they come within 12 and 15 feet of the door, the door will lock; this is how it would work on all the doors. He further stated that, " Then we switched over; we wanted the back doors locked all times; 4 (back) doors. " About a month ago, we got service from (a local technology company). " The Maintenance Director provided a bill, dated [DATE] for 2,529.47; Invoice #,[DATE], final billing for key pads, cable/wire, labor, etc.). The Maintenance Director stated this was for new key pads/ replacement keypads that he recommended (during the switch over). He further stated: " To get in the back door, you have to put the code in and out. Better off having them (the doors) locked at night; transient people walk by. "

Based upon policy review, record review, and interview, the facility failed to operationalize policies and procedures to prevent neglect and report neglect. The facility failed to provide the oversight and services needed to ensure the safety and well-being of one (#2) of one residents reviewed with known wandering behaviors at night of six sampled residents, due to her progressive dementia, and who was at risk for falls. Resident #2, an [AGE] year old long term care resident with a [DIAGNOSES REDACTED]. The facility did not conduct a thorough investigation of the event or prepare and submit required reports to the State Agency, consistent with facility policy. The lack of such an investigation resulted in failing to identify that the facility had neglected to provide one to one supervision on the 11:00 p.m. - 7:00 a.m. shifts from ,[DATE]-[DATE], the facility neglected to have a process for determining when a resident no longer needed to have one to one supervision, and the facility neglected to make it clear who was responsible to make such determinations. Based on observation, record and policy review, and interview, the facility also failed to operationalize policies and procedures to prevent occurrences of neglect related to resident elopement and conduct investigations and report such events for three occurrences, on [DATE] and [DATE], involving two (Residents #1 and 4) of six sampled residents which met the definition of elopement per the facility Elopement/Missing Resident policy. Resident #1 left the facility unwitnessed on [DATE], which the facility failed to identify as an elopement and implement proactive measures to prevent future occurrences; on [DATE], both Resident #1 and Resident #4 left the facility, without escort, and unwitnessed by staff. The facility's practices resulted in findings of immediate jeopardy which were on-going. Findings include: A review of the facility ' s " Abuse Prohibition " policy dated [DATE] revealed the following information. The policy stated, " The facility will prohibit abuse, neglect, involuntary seclusion, and misappropriation of all property for all residents through the following: Screening of potential hires, Training of employees (both new employees and ongoing training for all employees), Prevention of occurrences, Investigation of incidents and allegations, and Reporting of incidents, investigations, and center response to the results of their investigations." The policy defined neglect as, " Withholding of services from any resident unable to provide for self the services necessary to maintain physical and mental health. " Listed under " Procedure " , Part 4 included " Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property will include: A) identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. B) developing a care plan identifying appropriate intervention to prevent occurrences. " Record review of the Admission demographic information for Resident #2 revealed she was 89 years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. Per the "Rehabilitation Department Care Plan," dated [DATE], Resident #2 required "extensive assistance of one person with functional mobility/functional transfers" and "extensive assistance of one person with ambulation/gait" secondary to [DIAGNOSES REDACTED]. Patient is also in a wheelchair now and not ambulating due to safety concerns." Per the "Summary of Plan of Care" dated [DATE], Care Plan #009 "Has 1:1 aide due to resident continuing to wander, enter other residents ' rooms, take her clothes off multiple times per day, play with light switches, and falling." Care plan #039 reflected the resident had a history of [REDACTED]." Per the Care Area Assessment (CAA) documentation note, dated [DATE], "She (Resident #2) is currently on 1:1 care due to mood/behavior issues." Per the plan of care narrative summary, dated [DATE], "She (Resident #2) has required 1:1 aide due to her severe confusion and dementia." Review of the Care Area Assessment, which is part of the Resident Assessment Instrument, dated [DATE], found that Resident #2 was admitted to the facility related to worsening of dementia and behaviors at home. Following admission, she continued to present with behaviors of disrobing in public. She was restless, getting up and down and not sleeping at night. She had to adjust to the separation from her son who was at her side almost 24 hours a day when she was at home. A review of the Minimum Date Set (MDS) with an Assessment Reference Date of [DATE] revealed the following information: Section C-Cognitive Pattern: Subsection C0300: Resident #2 was unable to recall the year, month, and day of the week and scored as "0." Section C-[MEDICAL CONDITION]: Subsection C1300: Resident #2 was inattentive and had disorganized thinking and coded as " 1 " (Behavior continuously present, dose not fluctuate). Section D-Mood: Subsection D0200: Symptom Presence and frequency -Feeling down, depressed, or hopeless (,[DATE] days), trouble falling or staying asleep, or sleeping too much (,[DATE] days), poor appetite or overeating (,[DATE] days),trouble concentrating on things such as reading a newspaper or watching television (,[DATE] days), moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. (,[DATE] days). Section E-Behavior: Subsection E0200: Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching staff, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident displayed this type of behaviors ,[DATE] days, but less than daily. Subsection E0500: Impact on resident: Put the resident at significant risk for physical illness or injury? Coded as (1) Yes. E0900: Has the resident wandered? Coded as (2) Occurred ,[DATE] days, but less than daily. E1000 Wandering impact: Does the wandering place the resident at a significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Coded as (2) Occurred ,[DATE] days, but less than daily. Does the wandering significantly intrude on the privacy or activities of others? Coded as (1) Occurred ,[DATE] days, but less than daily. Section G: Functional Status: Subsection G0110: Bed mobility, transfers, and eating were coded as ,[DATE] (limited assistance with one person), walk in room and corridor, dressing, toilet use, and personal hygiene were coded as ,[DATE] (extensive assistance with one person), locomotion on and off the unit was coded as ,[DATE] (supervision with set up). Subsection G0300 Balance during transitions and walking were coded as (2) not steady, only able to stabilize with staff assistance. Subsection: G0600 Mobility devices: resident uses a walker and a wheelchair. A time line of events at the time and after the death of Resident #2 was provided by the Risk Manager and dated [DATE] with the following information. At 1:15 a.m. on [DATE], the Risk Manager was informed that Resident #2 " had fallen, was unresponsive and 911 had been called. " The Risk Manager arrived at the facility at approximately 2:37 a.m. Three police officers were standing at the nurse's station. The Risk Manager told the officers that she had to report the death to the Medical Examiner (ME) per the " Florida Guidelines for Long Term Care." The Risk Manager explained that the ME had to be called because the resident died after a fall. The Risk Manager informed the officers that she had to assess the resident and one of the officers went with her to the resident in the hallway. Resident #2's son was present at this time. The Risk Manager assessed the resident and found no bruising, lacerations, or discoloration to the front of her head. The back of the head was "intact and free of injury." A head to toe assessment revealed no injury, redness, swelling, or bruising. The resident had on "wet underwear, a gown and nothing on her feet." At approximately 2:45 a.m. the Medical Examiner called and asked what the police had determined and if the resident's physician would sign the death certificate. The RM told the ME what the police had determined and that the resident's physician would sign the death certificate. The funeral home arrived at 3:18 a.m. to receive the resident. The son for Resident #2 was present and left the facility with the funeral attendant and his mother. An interview was conducted with the Risk Manager on [DATE] at 9:05 a.m. during the entrance conference. When she was asked if the facility had a policy regarding one to one supervision and what the staff were supposed to do she said, "We do not have a policy. We provide one to one supervision only as a 'Courtesy'. We do not get a Doctor's order." When questioned further, the Risk Manager said if the psychiatrist determines a resident to be a danger to self or others he will order one to one supervision. The resident is kept on one to one supervision until the psychiatrist determines that it safe to discontinue the supervision. The Risk Manager said the floor nurses make the decision to place a resident on one to one supervision if a resident displays poor safety awareness. The floor nurse also determines when the one to one supervision is discontinued. A physician's order is not obtained when the need for increased supervision for safety is identified. When the Risk Manager was asked if there is a protocol for determining when the residents no longer need to have one to one supervision she said, "No." When asked if the nurse completes an assessment or documents the reasons why the resident no longer needs one to one supervision she said, "No." On [DATE] at 9:33 a.m. an interview was conducted with the Licensed Practical Nurse (LPN), Unit Manager (staff A). When asked why a resident would be placed on one to one supervision she said, "If they are unsafe on their own; if they are capable of walking but not by themselves; if they are impulsive and need to be supervised at all times." When asked about the process for determining if a resident should be put on one to one supervision she said, "Normally we talk to the Social Worker, Risk Manager, and Director of Nurses; it is usually a combination of person's making the decision." When asked if the floor nurses make the decision to take a resident off supervision she said, " We could suggest; I do not think that it would be our decision. " When asked if the resident would be automatically taken off one to one at the end of a shift, she said, "We would not decide that at the end of the shift. It would be decided during the day with the team." On [DATE] at 11:18 a.m. an interview was conducted with the station one 7:00 a.m. - 3:00 p.m. shift LPN (staff B). She was asked to verify her signature on a nurse's noted dated [DATE] at 12:00 p.m. that read, "1:1 continues" & she verified the signature as hers. When asked if she knew when Resident #2 was placed on one to one supervision she said, "I would have to look at the physician's order." When asked if it was her responsibility to remove a resident from one to one supervision, she said, "No, I have seen the Psychiatric doctor take someone off one to one." When asked the process of placing a resident on one to one supervision she said, "If there is a safety issue I would place a CNA with the resident." She confirmed she would then get a doctor's order. She said, the schedule was set to provide one to one supervision for Resident #2 on the 7:00 a.m. - 3:00 p.m. shift, but, did not know about the other shifts. On [DATE] at 10:52 a.m. an interview was conducted with the LPN (staff C) responsible for Resident #2 on the night of her death. She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She said, "We have less staff as opposed to the day shift." She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. When asked who determined that the resident didn't need to have one to one supervision from shift to shift she said, "The nurse." When asked if she decided Resident #2 did not need one to one supervision on the night the resident fell and subsequently died she said, "I did because the resident was in her bed with her eyes closed at the beginning of the shift." On [DATE] at approximately 10:30 a.m. an interview was conducted via the telephone with the Certified Nurse ' s Assistant (CNA), (staff F) that was assigned to provide care for Resident #2 on the night of the resident ' s death. Staff (F) confirmed that she had worked during the 11:00 p.m. - 7:00a.m. shift on [DATE] and confirmed she witnessed the event. She confirmed that Resident #2 was on her floor assignment which included the residents in rooms 172A through 180A. Staff (F) verified that her assignment did not include one to one supervision for Resident #2. Staff (F) revealed the following information regarding the occurrence involving Resident #2. She said she was coming out of a another resident ' s room making her rounds and saw Resident #2 a few doors down in the hallway. She said the resident voided on the floor and as she walked toward the resident, the resident slipped, fell , and hit her head on the wall. When staff (F) was asked what the resident was doing earlier in the shift, she said around shift change (11:00 p.m.) the resident was walking around in her room and in the hallway. Staff (F) said she redirected the resident back to bed and did not see her again until the fall. Staff (F) verified that she had provided one to one supervision on the 3:00 p.m. - 11:00p.m. shift on [DATE] but not on the 11:00p.m.-7:00a.m. shift. When staff (F) was asked if she saw anyone providing one to one supervision on [DATE] during the 11:00 p.m.-7:00a.m. shift, she said, " No I did not. " A review of the nurse ' s notes, dated [DATE] at 11:15 a.m. - [DATE] at 3:18 a.m., revealed the following information. The first documentation of "one to one supervision" was [DATE] at 2:50 a.m. "One to one supervision for safety purposes." There was no documentation from [DATE]-[DATE] to indicate that Resident #2 was assessed and determined to be safe without one to one supervision on the 11:00 p.m.-7:00 a.m. shift. There was no documentation in the nurses ' notes, additional assessments, or documentation presented by the facility that indicated the one to one supervision was to be done only on the 3:00 p.m.-11:00 p.m. and 7:00 a.m.-3:00 p.m. shifts. There was continued documentation in the nurses notes, dated [DATE] at 2:50 a.m., [DATE] at 4:30 a.m., [DATE] at 2:00 a.m., [DATE] at 7:30 a.m. (regarding 4:00 a.m. behaviors), [DATE] at 4:20 a.m., and [DATE] at 4:10 a.m., that indicated the need for one to one supervision on the 11:00 p.m.-7:00 a.m. for Resident #2. A review of the "Daily Skilled Nurse's Note" with directions at the top of the page that read: "For each shift, check all applicable boxes" revealed information for documentation of status and behaviors. On ,[DATE] and [DATE] for 11:00 p.m.-7:00 a.m. shift, the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern, " " wanders" and displayed "socially inappropriate behaviors." On [DATE] 11:00 p.m.-7:00 a.m. shift, the nurse checked the box that indicated the resident was "restless." On [DATE]-[DATE] for the 11:00 a.m.-7:00 a.m. shift, the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On [DATE] for the 11:00 p.m. - 7:00 a.m. shift, the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," and was "restless." On [DATE] for the 11:00 p.m.-7:00 a.m. shift, the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern, wanders, displayed socially inappropriate behaviors, and was restless." On the ,[DATE]-[DATE] 11:00 p.m. - 7:00 a.m. shift, the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated, had a change in usual sleep pattern, wanders, displayed socially inappropriate behaviors, and was "restless." A review of the nurse staffing sheet dated [DATE]-[DATE] revealed a staff member was assigned to provide one to one supervision on the following dates and shifts: [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m. Per the assignment sheets the facility did not schedule one to one supervision on the 11:00 p.m.-7:00 a.m. during the resident's entire stay including the night of her death at 1:00 a.m. on [DATE]. Per the admission nurse ' s note, dated [DATE] at 11:15 a.m., the resident was "Alert with confusion and short term memory loss. Primary language is Spanish but able to understand some English...As told to us by her son she (Resident #2) doesn't know her own limitations and frequently gets up and down." The following nurse ' s notes were found in the record: On [DATE] at 3:00 p.m., "Resident at nurse ' s station in wheelchair confused, looking for her son, attempting to stand up and run. After behavior was redirected, she then proceeded in taking her clothes off again behavior was redirected, she is now being propelled by staff around facility to divert her behavior. Safety maintained." On [DATE] at 12:15 a.m., "CNA is stationed outside of resident's room to better monitor resident." 2:00 a.m. "Resident placed in wheelchair because she wouldn't stay in bed and she was placed at the nurse's station. Resident would not stay seated. She would unlock the wheelchair wheels. Food was offered and accepted by resident. Resident continued to get up and then sit back down in wheelchair." At 2:50 a.m. "Assigned CNA came and got resident. Resident is sitting with CNA while in wheelchair. One on one supervision for safety purposes." On [DATE] at 4:30 a.m., "Resident has remained awake all night. CNA has had to do constant monitoring of the resident." On [DATE] at 7:00 a.m. "Late entry from [DATE] 945 a.m., observed the resident sitting in the floor ... the floor was wet with urine ....denies pain and discomfort." 9:40 p.m. "....continues to need someone with her. " On [DATE] at 7:30 a.m., "At 5:30 a.m. CNA reports resident sitting on CNAs backpack on the floor, resident spitting saliva in her hands and rubbing it in a circular motion on the floor. At 6:15 a.m. resident observed sitting on the day room floor again spitting saliva in hand and rubbing it in a circular motion on the floor the day room floor. " On [DATE] at 3:00 p.m., "Safety maintained. Will continue to monitor, 1:1 continues for safety." On [DATE] at 7:30 a.m., charting for 4:00 a.m. behaviors reflected, "Around 4:00 a.m. the resident was observed ambulating in other resident's rooms and going through drawers. Resident observed urinating on the floor next to roommate ' s bed. Observed resident sitting on roommate ' s bed with roommate in it. Resident constantly taking off clothes and refuses to allow staff to put back on pants and nonskid socks. Redirected multiple times to maintain safety. Resident closely monitored by staff to maintain safety." On [DATE] at 3:00 p.m., "1:1 continues. Resident restless, agitated." On [DATE] at 4:20 a.m., "Several attempts were made to redirect her but resisted. Eventually the staff took turns watching her while we worked to complete our duties ... ... towards the end of the shift after last rounds the assigned CNA had to continuously keep watch on her. She sat in her room with her or she would ambulate her through the halls." On [DATE] at 4:10 a.m., "Observed in another resident's room ...resisting care .....staff attempting multiple times to put resident in wheelchair however resident refuses ....resident attempted to sit in window sill. Notified RN risk manager via telephone of behavior. Resident made 1:1. " On [DATE] at 12:00 p.m., "1:1 continues .....MD in to see resident. New orders received to increase [MEDICATION NAME] to 50 mg PO BID ...son notified.....safety maintained. " On [DATE] at 9:00 p.m., "Resident continues on 1:1." On [DATE] at 1:00 a.m., "I (staff C) was walking into room [ROOM NUMBER] A .....I was in the doorway and looked to my right down the hall and saw Resident #2 slip. She had slipped in urine where she had voided right outside room [ROOM NUMBER]. She slipped backwards into the wall and was lying on her back with her head propped against the wall ... ....I ran to resident..... not responding to voice or touch...I called 911." On [DATE] at 11:25 a.m., an interview, via the telephone, was conducted with the facility's Medical Director and physician for Resident #2. He said he knew the resident had advanced dementia and a history of aggression. He said the facility notified him that the resident was continuing to have agitation. He ordered a psychiatric consult and increased the [MEDICATION NAME]. He did not recall if he had been notified of the resident's need for continued one to one supervision. On [DATE] at 4:37 p.m., a second interview was conducted, via the telephone, with the Medical Director and physician for Resident #2. He confirmed that he was aware of her death. He did not remember if he had been notified that the resident was on one to one supervision. When asked if it was important for him to be notified if the resident was on one to one supervision, but, such supervision was not being provided. He said, " Yes. It is important. I would want to know. " On [DATE] at 2:40 p.m. during an interview with the Risk Manager (RM) the following information was provided by the staff member. When asked what the process was for implementing one to one supervision the Risk Manager said, if the psychiatrist determined that a resident was not safe, he would order the resident to be one to one supervision and the resident would stay on such until the psychiatrist decided the resident was safe with the increased supervision. If the resident was determined to be safe without one to one supervision the resident was then put on the standard every two hours rounds. The psychiatrist was the only one who could decide whether or not the resident no longer needed one to one supervision. When asked if the psychiatrist is not involved in placing a resident on one to one supervision such as the case with Resident #2 she said, "The nurse assesses the situation if she feels that the resident needs additional supervision she will call the Director of Nurses, Assistant Director of Nurses, or the Risk Manager. They will let us know what is going on and we will put someone with them. " When asked if the nurses should be documenting the call the RM said," It is not written anywhere that they have to, it is at the nurse's discretion. " When asked if there was a formal process for discontinuing one to one supervision she said, " No there is not, only when a doctor has ordered a one to one, he has to come in to assess and he writes a discontinuation order. What happens is: the oncoming nurse looks at the situation; she looks and determines that a one to one comes off due to non-exhibiting of behaviors. " When asked, if there should be documentation of the absence of behaviors she said, " There should be. I, as a nurse, would document, resident no longer exhibiting behaviors. " When asked if she would specifically document the removal of the one to one, she said, " They have not been instructed to document the removal of the one to one. " When asked if the physician was notified when a resident was placed on one to one supervision, she said " No it is a nursing measure. " When asked if the physician was notified when the resident is removed from 1:1 supervision she said, " No. " On [DATE] at approximately 4:00 p.m. an additional interview was conducted with the Risk Manager. When asked if she had conducted an investigation related to Resident #2, she said, " Yes. I came into the building and started my investigation immediately. " Per the narrative time line of the events provided by the Risk Manager, dated [DATE], " at 11:15 p.m.-11:30 p.m., Resident #2 was taken to the bathroom by her Certified Nurse ' s Assistant (CNA); she was returned to bed and had non-skid socks placed back on her feet. At 1:00 a.m., the resident was seen in the hallway outside her room near the fire doors. She had urinated on the floor and was noted to have fallen. Staff attempted to reach her, however, not in time to prevent the fall. Emergency Medical Services (EMS) was called and subsequently the resident expired at 1:30 a.m. " The Risk Manager was asked if she filed an immediate and 5 day report as mandated, she said " No it was not abuse. " She did not say anything about neglect. When asked if she was going to file a report to the State Agency, she said, " I don ' t know. I ' m going to wait to see what you all (referring t to the survey team) find. " On [DATE] at 6:20 p.m. an interview was conducted with the Administrator. He said he was aware that Resident #2 was on 1:1 supervision on two shifts. He said he was aware that the facility did not have one to one supervision on the night shift because he understood the resident slept during the night. The Administrator said the facility was the process of training all employees and implementing the new policy related to 1:1 supervision. He said he was and will continue to have total involvement to ensure the process is complete. In addition, all the information will be brought to the Quality Assurance meeting and reviewed by the physician and Quality Assurance team. 2. A review of the facility policy and procedures, titled: Elopement/Missing Resident, effective, updated [DATE], stated a definition: Wandering is random and repetitive locomotion which may be goal directed (e.g., Resident appears to be looking for something such as an exit) or aimless or non -goal directed. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. * A resident wearing a secure care bracelet and/or a Roam alert bracelet whom exits a secured door in the vision of staff member the immediate response by the staff member when the alarm is sounding is Not considered an elopement. Resident is not in an unsafe area. * A resident wearing a secure care bracelet and/or a roam alert bracelet whom exits a secured door without being in vision of a staff member or without immediate response by a staff member and returned to a safe area when the staff responds; the staff could immediately respond to the alarm but if the resident is not secured and in a safe area under staff supervision should be considered an elopement. Resident is not in a safe area such as the parking lot or off of the property. The policy: The policy and procedure of (the facility) promotes a safe environment for residents and identifies residents at risk for elopement as well as interventions to follow when a resident has been identified as having eloped. A review of Resident #1 ' s clinical chart, documented that resident originally admitted to the facility [DATE] with a readmission on [DATE]. The resident was [AGE] years old. The record of admission listed [DIAGNOSES REDACTED]. An interview was conducted on [DATE] at approximately 11:15 a.m. with Staff Member E, a Licensed Practical Nurse. She stated that Resident #1 walked around the building a lot; " she is ambulatory, a quick walker; she walks, walks, walks, she doesn ' t talk to but a few people. " A review of Resident #1 ' s Care Plan, dated [DATE], reprinted [DATE], and updated on [DATE] documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place secure care monitoring device on Resident #1 and test secure care monitor every Sunday with hand held device; Allow to wander freely within facility but remove from area if annoying peers; Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. A review of Resident #1 ' s Care Plan, dated [DATE], updated on [DATE], documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place roam alert monitoring device on Resident and test roam alert placement every shift and function every Sunday and as needed. Replace roam alert upon expiration. Allow to wander freely within facility but redirect if needed. Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. Staff to perform every two hour visual verification of Resident location. A review of an MDS quarterly update, dated [DATE], in Section C0600, documented that Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS). Section C1300, Signs and symptoms of [MEDICAL CONDITION], documented that Resident #1 had continuous behavior present of inattention and disorganized thinking. An observation conducted on [DATE] at approximately 11:20 a.m., revealed Resident #1 walking down the hall. She was dressed for the day appropriately. She did not have shoes on, but, wore nonskid socks. Resident #1 approached the counter, looked at Staff Member E, looked at the surveyor and then walked away. Staff member E was observed to try to offer Resident #1 a cookie from the snack tray; however, the resident had walked away. The nurse followed and gave the cookie to the resident. A review of Resident #1 ' s Nurses ' Notes, dated [DATE] at 7:00 p.m. reflected: " Resident was seen outside front door at the porch area around 6:40 p.m. Brought back into the building. No apparent injuries observed. Easily re-directed. Responsible party notified. Dr. aware of incident, 1:1 service given this shift. " A review of Resident #1 ' s clinical chart for the

Based on record review and interviews the facility failed to follow the plan of care related to supervision for one (#2) of six residents who were reviewed for accidents and supervision. Documentation for Resident #2, who was [AGE] years old, detailed the resident's lack of safety awareness and the individualized plan of care included the need for one to one supervision to ensure the resident was safe and free from harm, beginning on [DATE] at 2:50 a.m. Though the documentation clearly demonstrated Resident #2 displayed poor safety awareness and restlessness on the 11:00 p.m. - 7:00 a.m. shift, the facility chose not to schedule additional staff to provide one to one supervision on the shift from [DATE] - [DATE], until the resident's death. Subsequently at 1:00 a.m. on [DATE], the resident walked out of her room without supervision, was incontinent of urine on the hallway floor, slipped in the urine, fell against the wall, slid to the floor and died in the hallway where she fell . Based on observation, record review, and interviews, the facility also failed to ensure the plan of care was followed to provide the oversight necessary to prevent three occurrences of resident elopement, on [DATE] and [DATE], involving two (Residents #1 and 4) of six sampled residents which met the definition of elopement per the facility Elopement/Missing Resident policy. Resident #1 left the facility, unwitnessed on [DATE], which the facility failed to identify as elopement and implement proactive measures to prevent future occurrences; on [DATE], both Resident #1 and Resident #4 left the facility, without escort, and unwitnessed by staff. The facility ' s failure to provide implement care plan measures resulted in findings of on-going immediate jeopardy. Findings: 1. Per the "Summary of Plan of Care" for Resident #2, dated [DATE], Care Plan #009 "Has 1:1 aide due to resident continuing to wander, enter other residents ' rooms, take her clothes off multiple times per day, play with light switches, and falling." Care plan #039ss reflected the resident had a history of [REDACTED]." Care Plan #709 " Resident is taken to activities by 1:1 aide. " Per the Care Area Assessment (CAA) documentation note, dated [DATE], "She (Resident #2) is currently on 1:1 care due to mood/behavior issues." Per the plan of care narrative summary, dated [DATE], "She (Resident #2) has required 1:1 aide due to her severe confusion and dementia." Per care plan #002 dated [DATE], under the Problem/Strengths column: " (Resident #2) is at risk for falls/injuries related to: history of falls, impaired memory, [MEDICAL CONDITION] drugs, mood/behavior issues ,unsteady gait/balance issues as well as functional and cognitive losses of dementia. " Under the intervention column dated [DATE] " 1:1 care as needed. " Per the "Rehabilitation Department Care Plan," dated [DATE], Resident #2 required "extensive assistance of one person with functional mobility/functional transfers" and "extensive assistance of one person with ambulation/gait" secondary to [DIAGNOSES REDACTED]. Patient is also in a wheelchair now and not ambulating due to safety concerns." Per the physical therapy note dated [DATE], " Patient continues to on 1 on 1 supervision. " Record review for Resident #2 revealed she was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the nurse ' s notes dated [DATE] at 11:15 a.m. - [DATE] at 3:18 a.m. revealed the following information. The first documentation of one to one supervision was [DATE] at 2:50 a.m. "One to one supervision for safety purposes." There was no documentation from [DATE]-[DATE] to indicate the resident was assessed and determined to be safe without one to one supervision on the 11:00 p.m.-7:00 a.m. shift. There was no documentation in the nurse ' s notes, additional assessments, or documentation presented by the facility that indicated the one to one supervision was to be done only on the 3:00 p.m.-11:00 p.m. and 7:00 a.m.-3:00 p.m. shifts. There was continued documentation in the nurses notes dated [DATE] at 2:50 a.m., [DATE] at 4:30 a.m., [DATE] at 2:00 a.m., [DATE] at 7:30 a.m. (regarding 4:00 a.m. behaviors), [DATE] at 4:20 a.m., and [DATE] at 4:10 a.m., that indicated the need for one to one supervision on the 11:00 p.m.-7:00 a.m. for Resident #2. An interview was conducted with the Risk Manager on [DATE] at 9:05 a.m. during the entrance conference. When she was asked if the facility had a policy regarding one to one supervision and what the staff were supposed to do she said, "We do not have a policy. We provide one to one supervision only as a 'Courtesy'. We do not get a Doctor's order." When questioned further, the Risk Manager said if the psychiatrist determines a resident to be a danger to self or others he will order one to one supervision. The resident is kept on one to one supervision until the psychiatrist determines that it safe to discontinue the supervision. The Risk Manager said the floor nurses make the decision to place a resident on one to one supervision if a resident displays poor safety awareness. The floor nurse also determines when the one to one supervision is discontinued. A physician's orders [REDACTED]. When the Risk Manager was asked if there is a protocol for determining when the residents no longer need to have one to one supervision she said, "No." When asked if the nurse completes an assessment or documents the reasons why the resident no longer needs one to one supervision she said, "No." A record review of the nurse's notes for Resident #2 from ,[DATE]-[DATE] revealed the following information. Per the admission nurse ' s note, dated [DATE], at 11:15 a.m., the resident was "Alert with confusion and short term memory loss. Primary language is Spanish but able to understand some English...As told to us by her son she (Resident #2) doesn't know her own limitations and frequently gets up and down." The following nurse ' s notes were found in the record: On [DATE] at 3:00 p.m., "Resident at nurse ' s station in wheelchair confused, looking for her son, attempting to stand up and run. After behavior was redirected she then proceeded in taking her clothes off again behavior was redirected, she is now being propelled by staff around facility to divert her behavior. Safety maintained." On [DATE] at 12:15 a.m., "CNA is stationed outside of resident's room to better monitor resident." On [DATE] at 2:00 a.m. "Resident placed in wheelchair because she wouldn't stay in bed and she was placed at the nurse's station. Resident would not stay seated. She would unlock the wheelchair wheels. Food was offered and accepted by resident. Resident continued to get up and then sit back down in wheelchair." On [DATE] at 2:50 a.m., "Assigned CNA came and got resident. Resident is sitting with CNA while in wheelchair. One on one supervision for safety purposes." On [DATE] at 4:30 a.m., "Resident has remained awake all night. CNA has had to do constant monitoring of the resident." On [DATE] at 7:00 a.m., "Late entry from [DATE] 9:45 a.m., observed the resident sitting on the floor ... the floor was wet with urine ....denies pain and discomfort." 9:40 p.m. "....continues to need someone with her. " On [DATE] at 7:30 a.m., "At 5:30 a.m. CNA reports resident sitting on CNAs backpack on the floor, resident spitting saliva in her hands and rubbing it in a circular motion on the floor. At 6:15 a.m. resident observed sitting on the day room floor again spitting saliva in hand and rubbing it in a circular motion on the floor the day room floor. " On [DATE] at 3:00 p.m., "Safety maintained. Will continue to monitor, 1:1 continues for safety." On [DATE] at 7:30 a.m., charting for 4:00 a.m. behaviors, "Around 4:00 a.m. the resident was observed ambulating in other resident's rooms and going through drawers. Resident observed urinating on the floor next to roommate ' s bed. Observed resident sitting on roommate ' s bed with roommate in it. Resident constantly taking off clothes and refuses to allow staff to put back on pants and nonskid socks. Redirected multiple times to maintain safety. Resident closely monitored by staff to maintain safety." On [DATE] at 3:00 p.m., "1:1 continues. Resident restless, agitated." On [DATE] at 4:20 a.m., "Several attempts were made to redirect her but resisted. Eventually the staff took turns watching her while we worked to complete our duties ... ... towards the end of the shift after last rounds the assigned CNA had to continuously keep watch on her. She sat in her room with her or she would ambulate her through the halls." On [DATE] at 4:10 a.m., "Observed in another resident's room ...resisting care .....staff attempting multiple times to put resident in wheelchair however resident refuses ....resident attempted to sit in window sill. Notified RN risk manager via telephone of behavior. Resident made 1:1. On [DATE] at 12:00 p.m., "1:1 continues .....MD in to see resident. New orders received to increase [MEDICATION NAME] to 50 mg PO BID ...son notified.....safety maintained. " On [DATE] at 9:00 p.m., "Resident continues on 1:1." On [DATE] at 1:00 a.m., "I (staff C) was walking into room [ROOM NUMBER]A .....I was in the doorway and looked to my right down the hall and saw Resident #2 slip. She had slipped in urine where she had voided right outside room [ROOM NUMBER]. She slipped backwards into the wall and was lying on her back with her head propped against the wall ... ....I ran to resident..... not responding to voice or touch...I called 911." A time line of events at the time and after the death of Resident #2 was provided by the Risk Manager and dated [DATE] with the following information. At 1:15 a.m. on [DATE], the Risk Manager was informed that Resident #2 " had fallen, was unresponsive and 911 had been called. " The Risk Manager arrived at the facility at approximately 2:37 a.m. Three police officers were standing at the nurse ' s station. The Risk Manager told the officers that she had to report the death to the Medical Examiner (ME) per the " Florida Guidelines for Long Term Care. " The Risk Manager explained that the ME had to be called because the resident died after a fall. The Risk Manager informed the officers that she had to assess the resident and one of the officers went with her to the resident in the hallway. Resident #2's son was present at this time. The Risk Manager assessed the resident and found no bruising, lacerations, or discoloration to the front of her head. The back of the head was " intact and free of injury. " A head to toe assessment revealed no injury, redness, swelling, or bruising. The resident had on "wet underwear, a gown and nothing on her feet." At approximately 2:45 a.m. the Medical Examiner called and asked what the police had determined and if the resident ' s physician would sign the death certificate. The RM told the ME what the police had determined and that the resident ' s physician would sign the death certificate. The funeral home arrived at 3:18 a.m. to receive the resident. The son for Resident #2 was present and left the facility with the funeral attendant and his mother. On [DATE] at 9:33 a.m. an interview was conducted with the Licensed Practical Nurse (LPN), Unit Manager (staff A). When asked why a resident would be placed one to one supervision she said, "If they are unsafe on their own; if they are capable of walking but not by themselves; if they are impulsive and need to be supervised at all times." When asked about the process for determining if a resident should be put on one to one supervision she said "Normally we talk to the Social Worker, Risk Manager, and Director of Nurses; it is usually a combination of person ' s making the decision." When asked if the floor nurses make the decision to take a resident off supervision she said, " We could suggest; I do not think that it would be our decision. " When asked if the resident would be automatically taken off one to one at the end of a shift, she said, "We would not decide that at the end of the shift. It would be decided during the day with the team." On [DATE] at 11:18 a.m. an interview was conducted with the Station One 7:00 a.m. - 3:00 p.m. shift LPN (staff B). She was asked to verify her signature on a nurse's noted, dated [DATE] at 12:00 p.m. that read, "1:1 continues" she verified the signature as hers. When asked if she knew when the resident was placed on one to one supervision she said, "I would have to look at the physician's orders [REDACTED]." When asked the process of placing a resident on one to one supervision she said, "If there is a safety issue I would place a CNA with the resident." She confirmed she would then get a doctor's order. She said, the schedule was set to provide one to one supervision for Resident #2 on the 7:00 a.m. - 3:00 p.m. shift but did not know about the other shifts. On [DATE] at 10:52 a.m. an interview was conducted with the LPN (staff C) responsible for Resident #2 on the night of her death. She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She said, "We have less staff as opposed to the day shift." When asked who determined that the resident didn't need to have one to one supervision from shift to shift she said, "The nurse." When asked if she decided Resident #2 did not need one to one supervision on the night the resident fell and subsequently died she said, "I did because the resident was in her bed with her eyes closed at the beginning of the shift." On [DATE] at approximately 10:30 a.m. an interview was conducted via the telephone with the Certified Nurse ' s Assistant (CNA), (staff F) that was assigned to provide care for Resident #2 on the night of the resident ' s death. Staff (F) confirmed that she had worked during the 11:00 p.m. - 7:00 a.m. shift on [DATE] and confirmed she witnessed the event. She confirmed that Resident #2 was on her floor assignment which included the residents in rooms 172A through 180A. Staff (F) verified that her assignment did not include one to one supervision for Resident #2. Staff (F) revealed the following information regarding the occurrence involving Resident #2. She said she was coming out of a another resident ' s room making her rounds and saw Resident #2 a few doors down in the hallway. She said the resident urinated on the floor and as she walked toward the resident, the resident slipped, fell , and hit her head on the wall. When staff (F) was asked what the resident was doing earlier in the shift, she said around shift change (11:00 p.m.) the resident was walking around in her room and in the hallway. Staff (F) said she redirected the resident back to bed and did not see her again until the fall. Staff (F) verified that she had provided one to one supervision on the 3:00 p.m. - 11:00 p.m. shift on [DATE] but not on the 11:00 p.m.-7:00 a.m. shift. When staff (F) was asked if she saw anyone providing one to one supervision on [DATE] during the 11:00 p.m.-7:00 a.m. shift, she said, " No I did not. " A review of the "Daily Skilled Nurse's Note" with directions at the top of the page that read: "For each shift, check all applicable boxes" revealed the following information. On ,[DATE] and [DATE] for 11:00 p.m.-7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern, "wanders" and displayed "socially inappropriate behaviors." On [DATE] 11:00 p.m.-7:00 a.m. the nurse checked the box that indicated the resident was "restless." On [DATE]-[DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On [DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," and was "restless." On [DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On ,[DATE]-[DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." A review of the nurse staffing sheet dated [DATE]-[DATE] revealed a staff member was assigned to provide one to one supervision on the following dates and shifts: [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m. Per the assignment sheets the facility did not schedule one to one supervision on the 11:00 p.m.-7:00 a.m. during the resident's entire stay including the night of her death at 1:00 a.m. on [DATE]. A review of the Minimum Date Sheet (MDS) with an Assessment Reference Date of [DATE] revealed the following information: Section C-Cognitive Pattern: Subsection C0300: Resident #2 was unable to recall the year, month, and day of the week and scored as " 0 " . Section C-[MEDICAL CONDITION]: Subsection C1300: Resident #2 was inattentive and had disorganized thinking and coded as " 1 " (Behavior continuously present, dose not fluctuate). Section D-Mood: Subsection D0200: Symptom Presence and frequency -Feeling down, depressed, or hopeless (,[DATE] days), trouble falling or staying asleep, or sleeping too much (,[DATE] days), poor appetite or overeating (,[DATE] days),trouble concentrating on things such as reading a newspaper or watching television (,[DATE] days), moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. (,[DATE] days). Section E-Behavior: Subsection E0200: Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching staff, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident displayed this type of behaviors ,[DATE] days, but less than daily. Subsection E0500: Impact on resident: Put the resident at significant risk for physical illness or injury? Coded as (1) Yes. E0900: Has the resident wandered? Coded as (2) Occurred ,[DATE] days, but less than daily. E1000 Wandering impact: Does the wandering place the resident at a significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Coded as (2) Occurred ,[DATE] days, but less than daily. Does the wandering significantly intrude on the privacy or activities of others? Coded as (1) Occurred ,[DATE] days, but less than daily. Section G: Functional Status: Subsection G0110: Bed mobility, transfers, and eating were coded as ,[DATE] (limited assistance with one person), walk in room and corridor, dressing, toilet use, and personal hygiene were coded as ,[DATE] (extensive assistance with one person), locomotion on and off the unit was coded as ,[DATE] (supervision with set up). Subsection G0300 Balance during transitions and walking were coded as (2) not steady, only able to stabilize with staff assistance. Subsection: G0600 Mobility devices: resident uses a walker and a wheelchair. On [DATE] at 11:25 a.m., an interview via the telephone was conducted with the facility's Medical Director and physician for Resident #2. He said he knew the resident had advanced dementia and a history of aggression. He said the facility notified him that the resident was continuing to have agitation. He ordered a psychiatric consult and increased the [MEDICATION NAME]. He did not recall if he had been notified of the resident's need for continued one to one supervision. On [DATE] at 4:37 p.m., a second interview was conducted via the telephone with the Medical Director and physician for Resident #2. He confirmed that he was aware of her death. He did not remember if he had been notified that the resident was on one to one supervision. When asked if it was important for him to be notified if the resident was on one to one supervision, but, such supervision was not being provided. He said " Yes. It is important. I would want to know. " On [DATE] at 2:40 p.m. during an interview with the Risk Manager (RM) the following information was revealed. When asked what the process was for implementing one to one supervision the Risk Manager said, if the psychiatrist determined that a resident was not safe, he would order the resident to be one to one supervision and the resident would stay on such until the psychiatrist decided the resident was safe with the increased supervision. If the resident was determined to be safe without one to one supervision the resident was then put on the standard every two hours rounds. The psychiatrist was the only one who could decide whether or not the resident no longer needed one to one supervision. When asked if the psychiatrist is not involved in placing a resident on one to one supervision such as the case with Resident #2 she said, " The nurse assesses the situation if she feels that the resident needs additional supervision she will call the Director of Nurses, Assistant Director of Nurses, or the Risk Manager. They will let us know what is going on and we will put someone with them. " When asked if the nurses should be documenting the call the RM said, " It is not written anywhere that they have to, it is at the nurse ' s discretion. " When asked if there was a formal process for discontinuing one to one supervision she said, " No there is not, only when a doctor has ordered a one to one , he has to come in to assess and he writes a discontinuation order. What happens is: the oncoming nurse looks at the situation, she looks and determines that a one to one comes off due to non-exhibiting of behaviors. " When asked, if there should be documentation of the absence of behaviors she said, " There should be. I, as a nurse, would document, " resident no longer exhibiting behaviors. " When asked if she would specifically document the removal of the one to one, she said, " They have not been instructed to document the removal of the one to one. " When asked if the physician was notified when a resident was placed on one to one supervision, she said " No it is a nursing measure. " When asked if the physician was notified when the resident is removed from 1:1 supervision she said, " No. " On [DATE] at 6:20 p.m. an interview was conducted with the Administrator. He said he was aware that Resident #2 was on 1:1 supervision on two shifts. He said he was aware that the facility did not have one to one supervision on the night shift because he understood the resident slept during the night. The Administrator said the facility was the process of training all employees and implementing meeting and reviewed by the physician and Quality the new policy related to 1:1 supervision. He said he was and will continue to have total involvement to ensure the process is complete. In addition, all the information will be brought to the Quality Assurance team. 2. During an interview conducted on [DATE] at 2:40 p.m. with the Risk Manager she revealed the following information. On [DATE] and again on [DATE] Resident #1 was found unsupervised outside the facility. Additionally on [DATE] a second resident (Resident #4) was found unsupervised outside the facility. A review of Resident #1 ' s Care Plan, dated [DATE], reprinted [DATE], and updated on [DATE] documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place secure care monitoring device on Resident #1 and test secure care monitor every Sunday with hand held device; Allow to wander freely within facility but remove from area if annoying peers; Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. A review of Resident #1 ' s Care Plan, dated [DATE], updated on [DATE], documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place roam alert monitoring device on Resident and test roam alert placement every shift and function every Sunday and as needed. Replace roam alert upon expiration. Allow to wander freely within facility but redirect if needed. Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. Staff to perform every two hour visual verification of Resident location. A review of an MDS quarterly update, dated [DATE], in Section C0600, documented that Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS). Section C1300, Signs and symptoms of [MEDICAL CONDITION], documented that Resident #1 had continuous behavior present of inattention and disorganized thinking. A review of Resident #1 ' s clinical chart, documented that the resident was originally admitted to the facility [DATE]; readmission of [DATE]; a [AGE] year old female. The Record of Admission listed [DIAGNOSES REDACTED]. A review of Resident #1 ' s nurses ' notes, dated [DATE] at 7:00 p.m., " Resident was seen outside front door at the porch area around 6:40 p.m. Brought back into the building. No apparent injuries observed. Easily re-directed. Responsible party notified. Dr. () aware of incident, 1:1 service given this shift. A review of Resident #1 ' s clinical chart, the [DATE] through [DATE] Physician orders, revealed nursing appliances for the resident included: " provide roam alert alarm to be at all times, check placement and function of roam alert every shift. " A review of the facility event log, documented that on [DATE] at 6:40 p.m.: " Visitor reported that resident was outside on the front porch with only socks on staff found resident standing in front of porch area easily redirected to building. The event was documented not to be an elopement event, or an adverse event, even though it met the definition of an elopement by the facility standards. A review of Resident #1 ' s Nurses notes, dated [DATE], 10:50 a.m. late entry: on [DATE] around 11:50 a.m., resident (#1) noted by dumpster by staff, staff assisted resident back into facility; no apparent injuries noted. MD, family notified, will continue to monitor resident. A review of Resident #1 ' s clinical chart, the [DATE] through [DATE] Physician orders, revealed that nursing appliances for the resident included: " check resident to have roam alert on at all times; check roam alert placement every shift. " An interview was conducted on [DATE] at approximately 11:15 a.m. with Staff Member E, a Licensed Practical Nurse. She stated that Resident #1 walks around the building a lot; she is ambulatory, a quick walker; she walks, walks, walks, she doesn ' t talk to but a few people. An observation conducted on [DATE] at approximately 11:20 a.m., revealed Resident #1 walking down the hall, she was dressed for the day appropriately, she did not have shoes on, but, she had nonskid socks on. Resident #1 approached the counter, looked Staff Member E, looked at the surveyor and then she walked away. Staff member E was observed to try to offer Resident #1 a cookie from the snack tray; resident had walked away; nurse followed and gave the cookie to the resident. An interview conducted on [DATE] at 3:00 p.m. with the Risk Manager (RM), she confirmed that the process of the facility for an event was for the staff to complete a form which described the event, and subsequently this form was reviewed by her and other members of management. A review of the event form was conducted, it was observed that a box in section 10, asked a question: Was person authorized to be at location of incident? For the event that occurred on [DATE] involving Resident #1, the RM confirmed that a LPN had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM confirmed that the staff member who saw Resident outside by the dumpster did not see the actual exit from the door by the resident. For the event that occurred on [DATE] involving Resident #1, the RM confirmed that a Licensed Practical Nurse (LPN) had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM further stated that it was a family member of another resident that had brought to their attention that Resident #1 had exited the front door during their entrance/exit to the facility while they were bringing items into the facility. The RM confirmed that staff had not witnessed Resident #1 exit the building. A review of Resident #4 ' s Plan of Care, dated [DATE], updated [DATE], documented a problem: Resident #4 is at risk for injury related to possible [MEDICAL CONDITION] activity due to [MEDICAL CONDITION]. Another problem documented for Resident #4 as of [DATE]: Resident #4 is at risk for falls/injuries related to decreased ADL ' s, History of falls, impaired vision, pain unsteady gait, [MEDICAL CONDITION], recent [MEDICAL CONDITION]. Further review of the Plan of care, dated [DATE], updated on [DATE]: Resident #4 is noted to have had an actual elopement from the facility. Resident #4 is at risk for further wandering from the facility unattended due to: wandered unattended from facility with anxiousness. The goal of the plan of care: Resident #4 will remain in a safe environment and have not further elopements thru next review date. Interventions listed, as of [DATE]: Complete every 15 minute checks on the resident until the risk manager including physician has time to review the elopement; Apply a roam alert bracelet; placement to be checked every shift and function checked every week replace roam alert upon expiration; Allow to wander freely within facility, but re-direct if needed; divert attention when becomes insistent on leaving facility; check promptly when alarm system goes off to ensure safety whereabouts. Redirect attention as needed; staff to perform every two hour visual verification of resident location. A review of the MDS Admission Assessment, dated [DATE], Section C-Cognitive Patterns, docum

Based on record review and interviews, the facility failed to provide oversight supervision to prevent injury for one (#2) of six residents who were reviewed for accidents and supervision. Documentation for Resident #2, an [AGE] year old long term care resident with a [DIAGNOSES REDACTED]. Documentation for Resident #2 detailed the resident ' s lack of safety awareness and the need for one to one supervision to ensure the resident was safe and free from harm beginning on [DATE] at 2:50 a.m. Though the documentation clearly demonstrated Resident #2 displayed poor safety awareness and restlessness on the 11:00 p.m. - 7:00 a.m. shift, the facility chose not to schedule additional staff to provide one to one supervision on the 11:00 p.m. - 7:00 a.m. shift from [DATE] - [DATE] until the resident ' s death. Subsequently at 1:00 a.m. on [DATE], the resident walked out of her room without supervision, voided on the hallway floor, slipped in the urine, fell against the wall, slid to the floor and died in the hallway where she fell . Based on observation, record review, and interviews, the facility also failed to provide the oversight necessary to prevent three occurrences of resident elopement, on [DATE] and [DATE], involving two (Residents #1 and 4) of six sampled residents which met the definition of elopement per the facility Elopement/Missing Resident policy. Resident #1 left the facility, unwitnessed on [DATE], which the facility failed to identify as elopement and implement proactive measures to prevent future occurrences; on [DATE], both Resident #1 and Resident #4 left the facility, without escort, and unwitnessed by staff. The facility's failure to provide the level of oversight necessary to ensure the safety and well-being of residents resulted in findings of on-going immediate jeopardy which is on-going. Findings: 1. Record review of the Admission demographic information for Resident #2 revealed she was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. A record review of the nurse ' s notes for Resident #2 from ,[DATE]-[DATE] revealed the following information. Per the admission nurses note dated [DATE] at 11:15 a.m. the resident was "Alert with confusion and short term memory loss. Primary language is Spanish but able to understand some English...As told to us by her son she (Resident #2) doesn't know her own limitations and frequently gets up and down." The following nurse ' s notes were found in the record: On [DATE] at 300 p.m., "Resident at nurse ' s station in wheelchair confused, looking for her son, attempting to stand up and run. After behavior was redirected she then proceeded in taking her clothes off again behavior was redirected, she is now being propelled by staff around facility to divert her behavior. Safety maintained." On [DATE] at 1215 a.m., "CNA is stationed outside of resident's room to better monitor resident." 2:00 a.m. "Resident placed in wheelchair because she wouldn't stay in bed and she was placed at the nurse's station. Resident would not stay seated. She would unlock the wheelchair wheels. Food was offered and accepted by resident. Resident continued to get up and then sit back down in wheelchair." 2:50 a.m. "Assigned CNA came and got resident. Resident is sitting with CNA while in wheelchair. One on one supervision for safety purposes." On [DATE] at 430 a.m., "Resident has remained awake all night. CNA has had to do constant monitoring of the resident." On [DATE] at 700 a.m. "Late entry from [DATE] 945 a.m., observed the resident sitting in the floor ... the floor was wet with urine ....denies pain and discomfort." 9:40 p.m. "....continues to need someone with her." On [DATE] at 730 a.m., "At 5:30 a.m. CNA reports resident sitting on CNAs backpack on the floor, resident spitting saliva in her hands and rubbing it in a circular motion on the floor. At 6:15 a.m. resident observed sitting on the day room floor again spitting saliva in hand and rubbing it in a circular motion on the floor the day room floor. On [DATE] at 3:00 p.m., "Safety maintained. Will continue to monitor, 1:1 continues for safety." On [DATE] at 7:30 a.m., charting for 4:00 a.m. behaviors, "Around 4:00 a.m. the resident was observed ambulating in other resident's rooms and going through drawers. Resident observed urinating on the floor next to roommate ' s bed. Observed resident sitting on roommate ' s bed with roommate in it. Resident constantly taking off clothes and refuses to allow staff to put back on pants and nonskid socks. Redirected multiple times to maintain safety. Resident closely monitored by staff to maintain safety." On [DATE] at 300 p.m., "1:1 continues. Resident restless, agitated." On [DATE] at 420 a.m., "Several attempts were made to redirect her but resisted. Eventually the staff took turns watching her while we worked to complete our duties ... ... towards the end of the shift after last rounds the assigned CNA had to continuously keep watch on her. She sat in her room with her or she would ambulate her through the halls." On [DATE] at 410 a.m., "Observed in another resident's room ...resisting care .....staff attempting multiple times to put resident in wheelchair however resident refuses ....resident attempted to sit in window sill. Notified RN risk manager via telephone of behavior. Resident made 1:1. On [DATE] at 1200 p.m., "1:1 continues .....MD in to see resident. New orders received to increase Seroquel to 50 mg PO BID ...son notified.....safety maintained. " On [DATE] at 900 p.m., "Resident continues on 1:1." On [DATE] at 100 a.m., "I (staff C) was walking into room #177 A .....I was in the doorway and looked to my right down the hall and saw Resident #2 slip. She had slipped in urine where she had voided right outside room #181. She slipped backwards into the wall and was lying on her back with her head propped against the wall ... ....I ran to resident..... not responding to voice or touch...I called 911." A time line of events at the time and after the death of Resident #2 was provided by the Risk Manager and dated [DATE] with the following information. At 1:15 a.m. on [DATE], the Risk Manager was informed that Resident #2 " had fallen, was unresponsive and 911 had been called. " The Risk Manager arrived at the facility at approximately 2:37 a.m. Three police officers were standing at the nurse ' s station. The Risk Manager told the officers that she had to report the death to the Medical Examiner (ME) per the " Florida Guidelines for Long Term Care. " The officer questioned why the ME had to be notified and said " we have already determined there is no foul play and the deceased is free of bruises or any marks that would indicate trauma. " The Risk Manager explained that the ME had to be called because the resident died after a fall. The Risk Manager informed the officers that she had to assess the resident and one of the officers went with her to the resident in the hallway. Resident #2 ' s son was present at this time. The Risk Manager assessed the resident and found no bruising, lacerations, or discoloration to the front of her head. The back of the head was " intact and free of injury. " A head to toe assessment revealed no injury, redness, swelling, or bruising. The resident had on " wet underwear, a gown and nothing on her feet. " At approximately 2:45 a.m. the Medical Examiner called and asked what the police had determined and if the resident ' s physician would sign the death certificate. The RM told the ME what the police had determined and that the resident ' s physician would sign the death certificate. The funeral home arrived at 3:18 a.m. to receive the resident. The son for Resident #2 was present and left the facility with the funeral attendant and his mother. An interview was conducted with the Risk Manager on [DATE] at 9:05 a.m. during the entrance conference. When she was asked if the facility had a policy regarding one to one supervision and what the staff were supposed to do she said, "We do not have a policy. We provide one to one supervision only as a 'Courtesy'. We do not get a Doctor's order." When questioned further, the Risk Manager said if the psychiatrist determines a resident to be a danger to self or others he will order one to one supervision. The resident is kept on one to one supervision until the psychiatrist determines that it safe to discontinue the supervision. The Risk Manager said the floor nurses make the decision to place a resident on one to one supervision if a resident displays poor safety awareness. The floor nurse also determines when the one to one supervision is discontinued. A physician's orders [REDACTED]. When the Risk Manager was asked if there is a protocol for determining when the residents no longer need to have one to one supervision she said, "No." When asked if the nurse completes an assessment or documents the reasons why the resident no longer needs one to one supervision she said, "No." On [DATE] at 9:33 a.m. an interview was conducted with the Licensed Practical Nurse (LPN), Unit Manager (staff A). When asked why a resident would be placed one to one supervision she said, "If they are unsafe on their own; if they are capable of walking but not by themselves; if they are impulsive and need to be supervised at all times." When asked about the process for determining if a resident should be put on one to one supervision she said "Normally we talk to the Social Worker, Risk Manager, and Director of Nurses; it is usually a combination of person ' s making the decision." When asked if the floor nurses make the decision to take a resident off supervision she said, " We could suggest; I do not think that it would be our decision. " When asked if the resident would be automatically taken off one to one at the end of a shift, she said, "We would not decide that at the end of the shift. It would be decided during the day with the team." On [DATE] at 11:18 a.m. an interview was conducted with the station one 7:00 a.m. - 3:00 p.m. shift LPN (staff B). She was asked to verify her signature on a nurse's noted dated [DATE] at 12:00 p.m. that read, "1:1 continues" she verified the signature as hers. When asked if she knew when the resident was placed on one to one supervision she said, "I would have to look at the physician's orders [REDACTED]." When asked the process of placing a resident on one to one supervision she said, "If there is a safety issue I would place a CNA with the resident." She confirmed she would then get a doctor's order. She said, the schedule was set to provide one to one supervision for Resident #2 on the 7:00 a.m. - 3:00 p.m. shift but did not know about the other shifts. On [DATE] at 10:52 a.m. an interview was conducted with the LPN (staff C) responsible for Resident #2 on the night of her death. She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She said, "We have less staff as opposed to the day shift." When asked who determined that the resident didn't need to have one to one supervision from shift to shift she said, "The nurse." When asked if she decided Resident #2 did not need one to one supervision on the night the resident fell and subsequently died she said, "I did because the resident was in her bed with her eyes closed at the beginning of the shift." On [DATE] at approximately 10:30 a.m. an interview was conducted via the telephone with the Certified Nurse ' s Assistant (CNA), (staff F) that was assigned to provide care for Resident #2 on the night of the resident ' s death. Staff (F) confirmed that she had worked during the 11:00 p.m. - 7:00 a.m. shift on [DATE] and confirmed she witnessed the event. She confirmed that Resident #2 was on her floor assignment which included the residents in rooms 172A through 180A. Staff (F) verified that her assignment did not include one to one supervision for Resident #2. Staff (F) revealed the following information regarding the occurrence involving Resident #2. She said she was coming out of a another resident ' s room making her rounds and saw Resident #2 a few doors down in the hallway. She said the resident urinated on the floor and as she walked toward the resident, the resident slipped, fell , and hit her head on the wall. When staff (F) was asked what the resident was doing earlier in the shift, she said around shift change (11:00 p.m.) the resident was walking around in her room and in the hallway. Staff (F) said she redirected the resident back to bed and did not see her again until the fall. Staff (F) verified that she had provided one to one supervision on the 3:00 p.m. - 11:00p.m. shift on [DATE] but not on the 11:00p.m.-7:00a.m. shift. When staff (F) was asked if she saw anyone providing one to one supervision on [DATE] during the 11:00 p.m.-7:00a.m. shift, she said, " No I did not. " A review of the nurse ' s notes dated [DATE] at 11:15 a.m. - [DATE] at 3:18 a.m. revealed the following information. The first documentation of "one to one supervision" was [DATE] at 2:50 a.m. "One to one supervision for safety purposes." There was no documentation from [DATE]-[DATE] to indicate the resident was assessed and determined to be safe without one to one supervision on the 11:00 p.m.-7:00 a.m. shift. There was no documentation in the nurse ' s notes, additional assessments, or documentation presented by the facility that indicated the one to one supervision was to be done only on the 3:00 p.m.-11:00 p.m. and 7:00 a.m.-3:00 p.m. shifts. There was continued documentation in the nurses notes dated [DATE] at 2:50 a.m., [DATE] at 4:30 a.m., [DATE] at 2:00 a.m., [DATE] at 7:30 a.m. (regarding 4:00 a.m. behaviors), [DATE] at 4:20 a.m., and [DATE] at 4:10 a.m., that indicated the need for one to one supervision on the 11:00 p.m.-7:00 a.m. for Resident #2. A review of the "Daily Skilled Nurse's Note" with directions at the top of the page that read: "For each shift, check all applicable boxes" revealed the following information. On ,[DATE] and [DATE] for 11:00 p.m.-7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern, "wanders" and displayed "socially inappropriate behaviors." On [DATE] 11:00 p.m.-7:00 a.m. the nurse checked the box that indicated the resident was "restless." On [DATE]-[DATE] for 11:00 a.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On [DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," and was "restless." On [DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On ,[DATE]-[DATE] for 11:00 p.m. - 7:00 a.m. the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." A review of the nurse staffing sheet dated [DATE]-[DATE] revealed a staff member was assigned to provide one to one supervision on the following dates and shifts: [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m. Per the assignment sheets the facility did not schedule one to one supervision on the 11:00 p.m.-7:00 a.m. during the resident's entire stay including the night of her death at 1:00 a.m. on [DATE]. Per the "Rehabilitation Department Care Plan," dated [DATE], Resident #2 required "extensive assistance of one person with functional mobility/functional transfers" and "extensive assistance of one person with ambulation/gait" secondary to [DIAGNOSES REDACTED]. Patient is also in a wheelchair now and not ambulating due to safety concerns." Per the "Summary of Plan of Care" dated [DATE], Care Plan #009 "Has 1:1 aide due to resident continuing to wander, enter other residents ' rooms, take her clothes off multiple times per day, play with light switches, and falling." Care plan #039 reflected the resident had a history of [REDACTED]." Per the Care Area Assessment (CAA) documentation note, dated [DATE], "She (Resident #2) is currently on 1:1 care due to mood/behavior issues." Per the plan of care narrative summary, dated [DATE], "She (Resident #2) has required 1:1 aide due to her severe confusion and dementia." Review of the Care Area Assessment, which is part of the Resident Assessment Instrument, dated [DATE], found that Resident #2 was admitted to the facility related to worsening of dementia and behaviors at home. Following admission, she continued to present with behaviors of disrobing in public. She was restless, getting up and down and not sleeping at night. She had to adjust to the separation from her son who was at her side almost 24 hours a day when she was at home. A review of the Minimum Date Set (MDS) with an Assessment Reference Date of [DATE] revealed the following information: Section C-Cognitive Pattern: Subsection C0300: Resident #2 was unable to recall the year, month, and day of the week and scored as " 0. " Section C-Delirium: Subsection C1300: Resident #2 was inattentive and had disorganized thinking and coded as " 1 " (Behavior continuously present, dose not fluctuate). Section D-Mood: Subsection D0200: Symptom Presence and frequency -Feeling down, depressed, or hopeless (,[DATE] days), trouble falling or staying asleep, or sleeping too much (,[DATE] days), poor appetite or overeating (,[DATE] days),trouble concentrating on things such as reading a newspaper or watching television (,[DATE] days), moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. (,[DATE] days). Section E-Behavior: Subsection E0200: Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching staff, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident displayed this type of behaviors ,[DATE] days, but less than daily. Subsection E0500: Impact on resident: Put the resident at significant risk for physical illness or injury? Coded as (1) Yes. E0900: Has the resident wandered? Coded as (2) Occurred ,[DATE] days, but less than daily. E1000 Wandering impact: Does the wandering place the resident at a significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Coded as (2) Occurred ,[DATE] days, but less than daily. Does the wandering significantly intrude on the privacy or activities of others? Coded as (1) Occurred ,[DATE] days, but less than daily. Section G: Functional Status: Subsection G0110: Bed mobility, transfers, and eating were coded as ,[DATE] (limited assistance with one person), walk in room and corridor, dressing, toilet use, and personal hygiene were coded as ,[DATE] (extensive assistance with one person), locomotion on and off the unit was coded as ,[DATE] (supervision with set up). Subsection G0300 Balance during transitions and walking were coded as (2) not steady, only able to stabilize with staff assistance. Subsection: G0600 Mobility devices: resident uses a walker and a wheelchair. On [DATE] at 11:25 a.m., an interview via the telephone was conducted with the facility's Medical Director and physician for Resident #2. He said he knew the resident had advanced dementia and a history of aggression. He said the facility notified him that the resident was continuing to have agitation. He ordered a psychiatric consult and increased the Seroquel. He did not recall if he had been notified of the resident's need for continued one to one supervision. On [DATE] at 4:37 p.m., a second interview was conducted via the telephone with the Medical Director and physician for Resident #2. He confirmed that he was aware of her death. He did not remember if he had been notified that the resident was on one to one supervision. When asked if it was important for him to be notified if the resident was on one to one supervision, but, such supervision was not being provided. He said " Yes. It is important. I would want to know. " On [DATE] at 2:40 p.m. during an interview with the Risk Manager (RM) the following information was revealed. When asked what the process was for implementing one to one supervision the Risk Manager said, if the psychiatrist determined that a resident was not safe, he would order the resident to be one to one supervision and the resident would stay on such until the psychiatrist decided the resident was safe with the increased supervision. If the resident was determined to be safe without one to one supervision the resident was then put on the standard every two hours rounds. The psychiatrist was the only one who could decide whether or not the resident no longer needed one to one supervision. When asked if the psychiatrist is not involved in placing a resident on one to one supervision such as the case with Resident #2 she said, " The nurse assesses the situation if she feels that the resident needs additional supervision she will call the Director of Nurses, Assistant Director of Nurses, or the Risk Manager. They will let us know what is going on and we will put someone with them. " When asked if the nurses should be documenting the call the RM said, " It is not written anywhere that they have to, it is at the nurse ' s discretion. " When asked if there was a formal process for discontinuing one to one supervision she said, " No there is not, only when a doctor has ordered a one to one , he has to come in to assess and he writes a discontinuation order. What happens is: the oncoming nurse looks at the situation, she looks and determines that a one to one comes off due to non-exhibiting of behaviors. " When asked, if there should be documentation of the absence of behaviors she said, " There should be. I as a nurse would document, resident no longer exhibiting behaviors. " When asked if she would specifically document the removal of the one to one, she said, " They have not been instructed to document the removal of the one to one. " When asked if the physician was notified when a resident was placed on one to one supervision, she said " No it is a nursing measure. " When asked if the physician was notified when the resident is removed from 1:1 supervision she said, " No. " On [DATE] at 6:20 p.m. an interview was conducted with the Administrator. He said he was aware that Resident #2 was on 1:1 supervision on two shifts. He said he was aware that the facility did not have one to one supervision on the night shift because he understood the resident slept during the night. The Administrator said the facility was the process of training all employees and implementing the new policy related to 1:1 supervision. He said he was and will continue to have total involvement to ensure the process is complete. In addition, all the information will be brought to the Quality Assurance meeting and reviewed by the physician and Quality Assurance team. 2. A review of Resident #1 ' s clinical chart, documented that resident originally admitted to the facility [DATE] with a readmission on [DATE]. The resident was [AGE] years old. The record of admission listed [DIAGNOSES REDACTED]. A review of an MDS quarterly update, dated [DATE], in Section C0600, documented that Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS). Section C1300, Signs and symptoms of delirium, documented that Resident #1 had continuous behavior present of inattention and disorganized thinking. A review of Resident #1 ' s Care Plan, dated [DATE], reprinted [DATE], and updated on [DATE] documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place secure care monitoring device on Resident #1 and test secure care monitor every Sunday with hand held device; Allow to wander freely within facility but remove from area if annoying peers; Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. A review of Resident #1 ' s Care Plan, dated [DATE], updated on [DATE], documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place roam alert monitoring device on Resident and test roam alert placement every shift and function every Sunday and as needed. Replace roam alert upon expiration. Allow to wander freely within facility but redirect if needed. Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. Staff to perform every two hour visual verification of resident location. An interview was conducted on [DATE] at approximately 11:15 a.m. with Staff Member E, a Licensed Practical Nurse. She stated that Resident #1 walked around the building a lot; " she is ambulatory, a quick walker; she walks, walks, walks, she doesn ' t talk to but a few people. " An observation conducted on [DATE] at approximately 11:20 a.m., revealed Resident #1 walking down the hall. She was dressed for the day appropriately. She did not have shoes on, but, wore nonskid socks. Resident #1 approached the counter, looked at Staff Member E, looked at the surveyor and then walked away. Staff member E was observed to try to offer Resident #1 a cookie from the snack tray; however, the resident had walked away. The nurse followed and gave the cookie to the resident. A review of Resident #1 ' s Nurses ' Notes, dated [DATE] at 7:00 p.m. reflected: " Resident was seen outside front door at the porch area around 6:40 p.m. Brought back into the building. No apparent injuries observed. Easily re-directed. Responsible party notified. Dr. aware of incident, 1:1 service given this shift. " A review of Resident #1 ' s clinical chart for the period from [DATE] through [DATE] found Physician orders [REDACTED]. " A review of the facility event log, documented that on [DATE] at 6:40 p.m.: " Visitor reported that resident was outside on the front porch with only socks on staff found resident standing in front of porch area easily redirected to building. " The event was documented not to be an elopement event or an event which is required to be reported to the State Agency, even though it met the definition of an elopement by the facility standards. Further review of Resident #1 ' s Nurses notes, dated [DATE] at 10:50 a.m. found a late entry which reflected that " on [DATE] around 11:50 a.m., resident (#1) noted by dumpster by staff, staff assisted resident back into facility; no apparent injuries noted. MD, family notified, will continue to monitor resident. " An interview conducted on [DATE] at 3:00 p.m. with the Risk Manager (RM), who confirmed that the process followed by the facility for an event was for the staff to complete a form which described the event, and subsequently this form was reviewed by her and other members of management. For the event that occurred on [DATE], the RM, confirmed that a Licensed Practical Nurse (LPN) had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM further stated that it was a family member of another resident that had brought to their attention that Resident #1 had exited the front door during their entrance/exit to the facility while they were bringing items into the facility. The RM confirmed that staff had not witnessed Resident #1 exit the building. For the event that occurred on [DATE], the RM, she confirmed that a LPN had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM confirmed that the staff member who saw Resident outside by the dumpster did not see the actual exit from the door by the resident. A review of the facility event log for ,[DATE] revealed an entry: [DATE], Resident #4, elopement. The log documented that the event occurred on [DATE] at 11:00 a.m.: " Resident noted to be outside and retuned to building without injury. He was outside approximately 5 minutes. He exited the front door after he and a friend ... " A review of a documented timeline, dated [DATE], for Resident #4, referenced the elopement event that occurred on [DATE] and included the following: On Monday, [DATE] at 11:30 a.m., I was notified by the unit manager on station 1 that Resident #4 had been found outside of the facility on the back side of the building by staff and returned without incident. The resident did have a Roam alert alarm on and all doors were locking correctly. In addition, the timeline documented an interview with a housekeeper, Staff Member G, who observed the resident outside: " I was outside at the picnic table when I look up and see the man walking next to the building. I know this was not right, so I walk up to him and say Hi. I asked him what he was doing and he said he was looking for his car but no could find it. He started walking away from me and I said I go with him and he was like no he can do it on his own. So I did not want him to go so I said do you know me what my name is and he said he knew me. I told him his car was up in the front parking and he said oh no and I say oh yes and I started him back to the door by the time clock and walked him in .... " The timeline for the [DATE] event for Resident #4 had no documentation of a staff member witnessing Resident #4 ' s unauthorized exit from the facility into unauthorized areas outside of the building. A review of

Based on record review, policy and procedure review, staff and administrative interviews, and job description review, it was determined that the facility failed to be managed in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for one (#2) of six residents reviewed related to supervision needs. The administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and did not have a process in place to ensure the facility did not neglect to provide supervision. Documentation for Resident #2, an [AGE] year old long term care resident with a [DIAGNOSES REDACTED]. Documentation for Resident #2 detailed the resident ' s lack of safety awareness and the need for one to one supervision to ensure the resident was safe and free from harm beginning on [DATE] at 2:50 a.m. Though the documentation clearly demonstrated Resident #2 displayed poor safety awareness and restlessness on the 11:00 p.m. - 7:00 a.m. shift, the facility chose not to schedule additional staff to provide one to one supervision on the 11:00 p.m. - 7:00 a.m. shift from [DATE] - [DATE] until the resident ' s death. Subsequently at 1:00 a.m. on [DATE], the resident walked out of her room without supervision, was incontinent of urine on the hallway floor, slipped in the urine, fell against the wall, slid to the floor and died in the hallway where she fell . Based on observation, record review, and interviews, the facility also failed to provide the oversight necessary to prevent three occurrences of resident elopement, on [DATE] and [DATE], involving two (Residents #1 and 4) of six sampled residents which met the definition of elopement per the facility Elopement/Missing Resident policy. Resident #1 left the facility, unwitnessed on [DATE], which the facility failed to identify as elopement and implement proactive measures to prevent future occurrences; on [DATE], both Resident #1 and Resident #4 left the facility, without escort, and unwitnessed by staff. The failure of the facility's Administration to meet its obligation to provide the level of oversight necessary to ensure the safety and well-being of residents resulted in findings of on-going immediate jeopardy which is on-going. Findings: A review of the administrator ' s job description signed (undated) by the administrator revealed the following information: General Job Summary: " The administrator delegates the overall operational responsibility for the efficient operation of the entire facility in accordance with the general objectives, policies and established philosophy. Has principle responsibility for the total optimal care of the residents and for the general welfare conditions of the employees. Places major emphasis on program development and coordination of services. " Specific duties: #14. " Complies with local, state, and federal licensing standards and requirements. " #29 " Enforces the rules and regulation relative to the level of health care and safety of residents, and to the protection of their personal and property rights. " On [DATE] at 6:20 p.m. an interview was conducted with the administrator. He said he was aware that Resident #2 was on 1:1 supervision on two shifts. He said he was aware that the facility did not have one to one supervision on the night shift because he understood the resident slept during the night. The administrator said the facility was the process of training all employees and implementing the new policy related to 1:1 supervision. He said he is and will continue to have total involvement to ensure the process is complete. In addition, all the information will be brought to the Quality Assurance meeting and reviewed by the physician and Quality Assurance team. Record review for Resident #2 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 2 was [AGE] years old. An interview was conducted with the Risk Manager on [DATE] at 9:05 a.m. during the entrance conference. When she was asked if the facility had a policy regarding one to one supervision and what the staff were supposed to do she said, "We do not have a policy. We provide one to one supervision only as a 'Courtesy'. We do not get a Doctor's order." When questioned further, the Risk Manager said if the psychiatrist determines a resident to be a danger to self or others he will order one to one supervision. The resident is kept on one to one supervision until the psychiatrist determines that it safe to discontinue the supervision. The Risk Manager said the floor nurses make the decision to place a resident on one to one supervision if a resident displays poor safety awareness. The floor nurse also determines when the one to one supervision is discontinued. A physician's orders [REDACTED]. When the Risk Manager was asked if there is a protocol for determining when the residents no longer need to have one to one supervision she said, "No." When asked if the nurse completes an assessment or documents the reasons why the resident no longer needs one to one supervision she said, "No." A record review of the nurse ' s notes for Resident #2 from ,[DATE]-[DATE] revealed the following information. Per the admission nurses note dated [DATE] at 11:15 a.m. the resident was "Alert with confusion and short term memory loss. Primary language is Spanish but able to understand some English...As told to us by her son she (Resident #2) doesn't know her own limitations and frequently gets up and down." The following nurse ' s notes were found in the record: On [DATE] at 3:00 p.m., "Resident at nurse ' s station in wheelchair confused, looking for her son, attempting to stand up and run. After behavior was redirected she then proceeded in taking her clothes off again behavior was redirected, she is now being propelled by staff around facility to divert her behavior. Safety maintained." On [DATE] at 1215 a.m., "CNA is stationed outside of resident's room to better monitor resident." 2:00 a.m. "Resident placed in wheelchair because she wouldn't stay in bed and she was placed at the nurse's station. Resident would not stay seated. She would unlock the wheelchair wheels. Food was offered and accepted by resident. Resident continued to get up and then sit back down in wheelchair." 2:50 a.m. "Assigned CNA came and got resident. Resident is sitting with CNA while in wheelchair. One on one supervision for safety purposes." On [DATE] at 4:30 a.m., "Resident has remained awake all night. CNA has had to do constant monitoring of the resident." On [DATE] at 7:00 a.m. "Late entry from [DATE] 945 a.m., observed the resident sitting in the floor ... the floor was wet with urine ....denies pain and discomfort." 9:40 p.m. "....continues to need someone with her. " On [DATE] at 7:30 a.m., "At 5:30 a.m. CNA reports resident sitting on CNAs backpack on the floor, resident spitting saliva in her hands and rubbing it in a circular motion on the floor. At 6:15 a.m. resident observed sitting on the day room floor again spitting saliva in hand and rubbing it in a circular motion on the floor the day room floor. On [DATE] at 3:00 p.m., "Safety maintained. Will continue to monitor, 1:1 continues for safety." On [DATE] at 7:30 a.m., charting for 4:00 a.m. behaviors, "Around 4:00 a.m. the resident was observed ambulating in other resident's rooms and going through drawers. Resident observed urinating on the floor next to roommate ' s bed. Observed resident sitting on roommate ' s bed with roommate in it. Resident constantly taking off clothes and refuses to allow staff to put back on pants and nonskid socks. Redirected multiple times to maintain safety. Resident closely monitored by staff to maintain safety." On [DATE] at 4:20 a.m., "Several attempts were made to redirect her but resisted. Eventually the staff took turns watching her while we worked to complete our duties ... ... towards the end of the shift after last rounds the assigned CNA had to continuously keep watch on her. She sat in her room with her or she would ambulate her through the halls." On [DATE] at 4:10 a.m., "Observed in another resident's room ...resisting care .....staff attempting multiple times to put resident in wheelchair however resident refuses ....resident attempted to sit in window sill. Notified RN risk manager via telephone of behavior. Resident made 1:1. On [DATE] at 12:00 p.m., "1:1 continues .....MD in to see resident. New orders received to increase [MEDICATION NAME] to 50 mg PO BID ...son notified.....safety maintained. " On [DATE] at 9:00 p.m., "Resident continues on 1:1." On [DATE] at 1:00 a.m., "I (staff C) was walking into room [ROOM NUMBER] A .....I was in the doorway and looked to my right down the hall and saw Resident #2 slip. She had slipped in urine where she had voided right outside room [ROOM NUMBER]. She slipped backwards into the wall and was lying on her back with her head propped against the wall ... ....I ran to resident..... not responding to voice or touch...I called 911." A time line of events at the time and after the death of Resident #2 was provided by the risk manager and dated [DATE]. At 1:15 a.m. on [DATE], the risk manager was informed that Resident #2 " had fallen, was unresponsive and 911 had been called. " The risk manager arrived at the facility at approximately 2:37 a.m. Three police officers were standing at the nurse ' s station. The risk manager told the officers that she had to report the death to the Medical Examiner (ME) per the " Florida Guidelines for Long Term Care." The risk manager explained that the ME has to be called because the resident died after a fall. The risk manager informed the officers that she had to assess the resident and one of the officers went with her to the resident in the hallway. Resident #2 ' s son was present at this time. The risk manager assessed the resident and found no bruising, lacerations, or discoloration to the front of her head. The back of the head was " intact and free of injury. " A head to toe assessment revealed no injury, redness, swelling, or bruising. The resident had on " wet underwear, a gown and nothing on her feet." At approximately 2:45 a.m. the Medical Examiner called and asked what the police had determined and if the resident ' s physician would sign the death certificate. The RM told the ME what the police had determined and that the resident ' s physician would sign the death certificate. The son for Resident #2 was present and left the facility with the funeral attendant and his mother. On [DATE] at 9:33 a.m. an interview was conducted with the Licensed Practical Nurse (LPN), Unit Manager (staff A). When asked why a resident would be placed one to one supervision she said, "If they are unsafe on their own; if they are capable of walking but not by themselves; if they are impulsive and need to be supervised at all times." When asked about the process for determining if a resident should be put on one to one supervision she said "Normally we talk to the Social Worker, Risk Manager, and Director of Nurses; it is usually a combination of person ' s making the decision." When asked if the floor nurses make the decision to take a resident off supervision she said, " We could suggest; I do not think that it would be our decision. " When asked if the resident would be automatically taken off one to one at the end of a shift, she said, "We would not decide that at the end of the shift. It would be decided during the day with the team." On [DATE] at 11:18 a.m. an interview was conducted with the station one 7:00 a.m. - 3:00 p.m. shift LPN (staff B). She was asked to verify her signature on a nurse's noted dated [DATE] at 12:00 p.m. that read, "1:1 continues" she verified the signature as hers. When asked if she knew when the resident was placed on one to one supervision she said, "I would have to look at the physician's orders [REDACTED]." When asked the process of placing a resident on one to one supervision she said, "If there is a safety issue I would place a CNA with the resident." She confirmed she would then get a doctor's order. She said, the schedule was set to provide one to one supervision for Resident #2 on the 7:00 a.m. - 3:00 p.m. shift but did not know about the other shifts. On [DATE] at 10:52 a.m. an interview was conducted with the LPN (staff C) responsible for Resident #2 on the night of her death. She said Resident #2 never had a scheduled staff member assigned to provide one to one supervision on the 11:00 p.m.-7:00 a.m. shift. She said, "We have less staff as opposed to the day shift." When asked who determined that the resident didn't need to have one to one supervision from shift to shift she said, "The nurse." When asked if she decided Resident #2 did not need one to one supervision on the night the resident fell and subsequently died she said, "I did because the resident was in her bed with her eyes closed at the beginning of the shift." On [DATE] at approximately 10:30 a.m. an interview was conducted via the telephone with the Certified Nurse ' s Assistant (CNA), (staff F) that was assigned to provide care for Resident #2 on the night of the resident ' s death. Staff (F) confirmed that she had worked during the 11:00 p.m. - 7:00 a.m. shift on [DATE] and confirmed she witnessed the event. She confirmed that Resident #2 was on her floor assignment which included the residents in rooms 172A through 180A. Staff (F) verified that her assignment did not include one to one supervision for Resident #2. Staff (F) revealed the following information regarding the occurrence involving Resident #2. She said she was coming out of a another resident ' s room making her rounds and saw Resident #2 a few doors down in the hallway. She said the resident urinated on the floor and as she walked toward the resident, the resident slipped, fell , and hit her head on the wall. When staff (F) was asked what the resident was doing earlier in the shift, she said around shift change (11:00 p.m.) the resident was walking around in her room and in the hallway. Staff (F) said she redirected the resident back to bed and did not see her again until the fall. Staff (F) verified that she had provided one to one supervision on the 3:00 p.m. - 11:00 p.m. shift on [DATE] but not on the 11:00 p.m.-7:00 a.m. shift. When staff (F) was asked if she saw anyone providing one to one supervision on [DATE] during the 11:00 p.m.-7:00 a.m. shift, she said, " No I did not. " On [DATE] at 11:25 a.m., an interview via the telephone was conducted with the facility's Medical Director and physician for Resident #2. He said he knew the resident had advanced dementia and a history of aggression. He said the facility notified him that the resident was continuing to have agitation. He ordered a psychiatric consult and increased the [MEDICATION NAME]. He did not recall if he had been notified of the resident's need for continued one to one supervision. On [DATE] at 4:37 p.m., a second interview was conducted via the telephone with the Medical Director and physician for Resident #2. He confirmed that he was aware of her death. He did not remember if he had been notified that the resident was on one to one supervision. When asked if it was important for him to be notified if the resident was on one to one supervision, but, such supervision was not being provided. He said " Yes. It is important. I would want to know. " A review was completed of the nurse ' s notes dated [DATE] at 11:15 a.m. - [DATE] at 3:18 a.m. The first documentation of "one to one supervision" was [DATE] at 2:50 a.m. "One to one supervision for safety purposes." There was no documentation from [DATE]-[DATE] to indicate the resident was assessed and determined to be safe without one to one supervision on the 11:00 p.m.-7:00 a.m. shift. There was no documentation in the nurse ' s notes, additional assessments, or documentation presented by the facility that indicated the one to one supervision was to be done only on the 3:00 p.m.-11:00 p.m. and 7:00 a.m.-3:00 p.m. shifts. There was continued documentation in the nurses notes dated [DATE] at 2:50 a.m., [DATE] at 4:30 a.m., [DATE] at 2:00 a.m., [DATE] at 7:30 a.m. (regarding 4:00 a.m. behaviors), [DATE] at 4:20 a.m., and [DATE] at 4:10 a.m., that indicated the need for one to one supervision on the 11:00 p.m.-7:00 a.m. for Resident #2. A review of the "Daily Skilled Nurse's Note" with directions at the top of the page that read: "For each shift, check all applicable boxes" revealed the following information. On ,[DATE] and [DATE] for the 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern, "wanders" and displayed "socially inappropriate behaviors." On [DATE] 11:00 p.m.-7:00 a.m., the nurse checked the box that indicated the resident was "restless." On [DATE]-[DATE] for 11:00 a.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On [DATE] for 11:00 p.m. - 7:00 a.m., the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," and was "restless." On [DATE] for 11:00 p.m.-7:00 a.m., the nurse made a check mark in the boxes that indicated the resident had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." On ,[DATE]-[DATE] for 11:00 p.m. - 7:00 a.m., the nurse made a check mark in the boxes that indicated the resident was "anxious/agitated," had a "change in usual sleep pattern," "wanders," displayed "socially inappropriate behaviors," and was "restless." A review of the nurse staffing sheet, dated [DATE]-[DATE], revealed a staff member was assigned to provide one to one supervision on the following dates and shifts: [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m., [DATE] 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m. Per the assignment sheets, the facility did not schedule one to one supervision on the 11:00 p.m.-7:00 a.m. during the resident's entire stay, including the night of her death at 1:00 a.m. on [DATE]. Per the "Rehabilitation Department Care Plan," dated [DATE], Resident #2 required "extensive assistance of one person with functional mobility/functional transfers" and "extensive assistance of one person with ambulation/gait" secondary to [DIAGNOSES REDACTED]. Patient is also in a wheelchair now and not ambulating due to safety concerns." Per the "Summary of Plan of Care" dated [DATE], Care Plan #009 "Has 1:1 aide due to resident continuing to wander, enter other residents ' rooms, take her clothes off multiple times per day, play with light switches, and falling." Care plan #039 reflected the resident had a history of [REDACTED]." Per the Care Area Assessment (CAA) documentation note, dated [DATE], "She (Resident #2) is currently on 1:1 care due to mood/behavior issues." Per the plan of care narrative summary, dated [DATE], "She (Resident #2) has required 1:1 aide due to her severe confusion and dementia." Review of the Care Area Assessment, which is part of the Resident Assessment Instrument, dated [DATE], found that Resident #2 was admitted to the facility related to worsening of dementia and behaviors at home. Following admission, she continued to present with behaviors of disrobing in public. She was restless, getting up and down and not sleeping at night. She had to adjust to the separation from her son who was at her side almost 24 hours a day when she was at home. A review of the Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed the following information: Section C-Cognitive Pattern: Subsection C0300: Resident #2 was unable to recall the year, month, and day of the week and scored as " 0 " . Section C-[MEDICAL CONDITION]: Subsection C1300: Resident #2 was inattentive and had disorganized thinking and coded as " 1 " (Behavior continuously present, dose not fluctuate). Section D-Mood: Subsection D0200: Symptom Presence and frequency -Feeling down, depressed, or hopeless (,[DATE] days), trouble falling or staying asleep, or sleeping too much (,[DATE] days), poor appetite or overeating (,[DATE] days),trouble concentrating on things such as reading a newspaper or watching television (,[DATE] days), moving or speaking so slowly that other people could have noticed or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. (,[DATE] days). Section E-Behavior: Subsection E0200: Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching staff, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident displayed this type of behaviors ,[DATE] days, but less than daily. Subsection E0500: Impact on resident: Put the resident at significant risk for physical illness or injury? Coded as (1) Yes. E0900: Has the resident wandered? Coded as (2) Occurred ,[DATE] days, but less than daily. E1000 Wandering impact: Does the wandering place the resident at a significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Coded as (2) Occurred ,[DATE] days, but less than daily. Does the wandering significantly intrude on the privacy or activities of others? Coded as (1) Occurred ,[DATE] days, but less than daily. Section G: Functional Status: Subsection G0110: Bed mobility, transfers, and eating were coded as ,[DATE] (limited assistance with one person), walk in room and corridor, dressing, toilet use, and personal hygiene were coded as ,[DATE] (extensive assistance with one person), locomotion on and off the unit was coded as ,[DATE] (supervision with set up). Subsection G0300 Balance during transitions and walking were coded as (2) not steady, only able to stabilize with staff assistance. Subsection: G0600 Mobility devices: resident uses a walker and a wheelchair. Additional information was provided on [DATE] at 2:40 p.m. during an interview with the Risk Manager (RM). When asked what the process was for implementing one to one supervision the Risk Manager said, if the psychiatrist determined that a resident was not safe, he would order the resident to be one to one supervision and the resident would stay on such until the psychiatrist decided the resident was safe with the increased supervision. If the resident was determined to be safe without one to one supervision the resident was then put on the standard every two hours rounds. The psychiatrist was the only one who could decide whether or not the resident no longer needed one to one supervision. When asked if the psychiatrist is not involved in placing a resident on one to one supervision such as the case with Resident #2 she said, " The nurse assesses the situation if she feels that the resident needs additional supervision she will call the Director of Nurses, Assistant Director of Nurses, or the Risk Manager. They will let us know what is going on and we will put someone with them. " When asked if the nurses should be documenting the call the RM, she said, " It is not written anywhere that they have to, it is at the nurse ' s discretion. " When asked if there was a formal process for discontinuing one to one supervision she said, " No there is not, only when a doctor has ordered a one to one, he has to come in to assess and he writes a discontinuation order. What happens is: the oncoming nurse looks at the situation, she looks and determines that a one to one comes off due to non-exhibiting of behaviors. " When asked, if there should be documentation of the absence of behaviors she said, " There should be. I as a nurse would document, resident no longer exhibiting behaviors. " When asked if she would specifically document the removal of the one to one, she said, " They have not been instructed to document the removal of the one to one. " When asked if the physician was notified when a resident was placed on one to one supervision, she said, " No it is a nursing measure. " When asked if the physician was notified when the resident is removed from 1:1 supervision she said, " No. " Review of the Care Area Assessment, which is part of the Resident Assessment Instrument, dated [DATE], found that Resident #2 was admitted to the facility related to worsening of dementia and behaviors at home. Following admission, she continued to present with behaviors of disrobing in public. She was restless, getting up and down and not sleeping at night. She had to adjust to the separation from her son who was at her side almost 24 hours a day when she was at home. 2. During an interview conducted on [DATE] at 2:40 p.m. with the Risk Manager she revealed the following information. On [DATE] and again on [DATE] Resident #1 was found unsupervised outside the facility. Additionally on [DATE], a second resident (Resident #4) was found unsupervised outside the facility. During the interview conducted on [DATE] at approximately 10:30 a.m. with the Administrator, he stated the entire building is locked, except for the front (door) that is open from around 7:00 a.m. to 8:00 p.m. He stated that the wander guard locks the door. Beyond the open time, we use the key pad. A previous interview was conducted on [DATE] at approximately 10:30 a.m. with the Risk Manager who stated that the facility uses Roam Alerts. It is a band on the ankle, or if we have a wheel chair bound person, it will be on the w/c. A review of Resident #1 ' s clinical chart, documented that the resident was originally admitted to the facility [DATE]; readmission of [DATE]; a [AGE] year old female. The Record of Admission listed [DIAGNOSES REDACTED]. A review of Resident #1 ' s nurses' notes, dated [DATE] at 7:00 p.m., " Resident was seen outside front door at the porch area around 6:40 p.m. Brought back into the building. No apparent injuries observed. Easily re-directed. Responsible party notified. Dr. aware of incident, 1:1 service given this shift. A review of Resident #1 ' s clinical chart, the [DATE] through [DATE] Physician orders, revealed nursing appliances for the resident included: " provide roam alert alarm to be at all times, check placement and function of roam alert every shift. " A review of the facility event log, documented that on [DATE] at 6:40 p.m.: " Visitor reported that resident was outside on the front porch with only socks on staff found resident standing in front of porch area easily redirected to building." The event was documented not to be an elopement event, or an event which required a report to the State Agency, even though it met the definition of an elopement by the facility standards. A review of Resident #1 ' s Nurses notes, dated [DATE], 10:50 a.m. late entry: on [DATE] around 11:50 a.m., "resident (#1) noted by dumpster by staff, staff assisted resident back into facility; no apparent injuries noted. MD, family notified, will continue to monitor resident." A review of Resident #1 ' s clinical chart, the [DATE] through [DATE] Physician orders, revealed that nursing appliances for the resident included: " check resident to have roam alert on at all times; check roam alert placement every shift. " An interview was conducted on [DATE] at approximately 11:15 a.m. with Staff Member E, a Licensed Practical Nurse. She stated that Resident #1" walks around the building a lot; she is ambulatory, a quick walker; she walks, walks, walks, she doesn ' t talk to but a few people." A review of Resident #1 ' s Care Plan, dated [DATE], reprinted [DATE], and updated on [DATE] documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place secure care monitoring device on Resident #1 and test secure care monitor every Sunday with hand held device; Allow to wander freely within facility but remove from area if annoying peers; Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. A review of Resident #1 ' s Care Plan, dated [DATE], updated on [DATE], documented a problem area: Resident #1 at risk for wandering from facility D/T (due to): Dementia/Communication barriers. The goal of the plan of care: Resident #1 will not wander from the facility unattended. Interventions listed, as of [DATE], included: Place roam alert monitoring device on Resident and test roam alert placement every shift and function every Sunday and as needed. Replace roam alert upon expiration. Allow to wander freely within facility but redirect if needed. Divert attention when Resident becomes insistent on leaving facility. Check promptly when alarm system goes off to ensure Resident safety/whereabouts. Redirect Resident attention as needed. Staff to perform every two hour visual verification of Resident location. A review of an MDS quarterly update, dated [DATE], in Section C0600, documented that Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS). Section C1300, Signs and symptoms of [MEDICAL CONDITION], documented that Resident #1 had continuous behavior present of inattention and disorganized thinking. An observation conducted on [DATE] at approximately 11:20 a.m., revealed Resident #1 walking down the hall, she was dressed for the day appropriately, she did not have shoes on, but, she had nonskid socks on. Resident #1 approached the counter, looked Staff Member E, looked at the surveyor and then she walked away. Staff member E was observed to try to offer Resident #1 a cookie from the snack tray; resident had walked away; the nurse followed and gave the cookie to the resident. An interview conducted on [DATE] at 3:00 p.m. with the Risk Manager (RM), she confirmed that the process of the facility for an event was for the staff to complete a form which described the event, and subsequently this form was reviewed by her and other members of management. For the event that occurred on [DATE] involving Resident #1, the RM confirmed that a Licensed Practical Nurse (LPN) had completed a description of the event and had documented that Resident #1 was not authorized to be in the location that she was found in and that it was an unauthorized exit from the facility. The RM further stated that it was a fam

Based on interviews and record review the facility failed to provide adequate supervision to maintain a safe and accident free environment for one of 35 residents reviewed ( #51).Resident #51, an alert and oriented resident, sustained a fall that resulted in a serious head injury, requiring an emergency transfer to a trauma hospital. The facility also failed to ensure that the environment was free of accident hazards on one of two nursing stations. Findings include: Resident #51 was admitted to the facility on [DATE] for rehabilitation and aftercare from a hospitalization for pelvic pain and dehydration. Per the facility face sheet she was [AGE] years old. Review of a hospital physician 's history and physical, dated 04/26/12, she was admitted with chronic pelvic pain that had become acute. The past medical history stated she had chronic cystitis (inflamed bladder), non-insulin dependent diabetes, and hypertension. Her past surgical history included a right nephrectomy. A hospital urology consult, dated 04/29/12, stated she was found to have a chronic UTI for three years, with incontinence, and wore paper briefs. She had a surgical removal of the right kidney at age 16. She had a normal gait, and no areas of focal weakness in the neurological exam. She was alert, cooperative and oriented. Mood and affect were appropriate. She was found to have a left hydro[DIAGNOSES REDACTED] with an abnormality of the distal urethra/ bladder area. Upon admission to the skilled nursing facility on 05/02/12, the admission assessment stated she had pain, hypertension, UTI, Diabetes, depression and an ulcer of the left heel. She was legally deaf, with fair vision. A health care surrogate form was dated 01/19/12. The MDS (Minimum Data Set) , dated 05/30/12, stated the BIMS (Brief Mental Screening) score was 15 of 15, with the mood and behavior section zero, indicating no behaviors. Section G stated she required the extensive assistance of two staff members for transfers, mobility, and toilet use. Balance was not steady and she was only able to stabilize with staff assistance. She used a walker and wheelchair for mobility. Section H stated she was frequently incontinent. On 05/23/12 a urine culture grew Pseudomonas bacteria from a voided specimen. She was ordered oral antibiotics. A physical therapy (PT) progress note on 05/29/12 stated she demonstrated gait ability with front wheeled walker on even surfaces and required contact guard assistance up to 100 feet. She was able to safely transition from sit to stand with stand by assistance. An OT therapy notes stated on 05/23/12 the self care toileting goal was met and she was able to safely perform all toileting tasks requiring only stand by assistance. On 06/04/12 at 6:00 a.m. the blood sugar was 48. She was alert and responsive. A snack was given. There was no documentation that the physician was notified. Review of the nurse' s notes at 4:00 p.m. revealed that the blood sugar was 317. There was no documentation regarding her status and no documentation that the physician was notified. At 9:30 p.m. the nurse wrote that she gave a nutritional supplement of Med Pass 120 ml. and the resident stated to the nurse that she ate six crackers with peanut butter. She was awake, alert, and cooperative. She had no complaints. Review of the facility nurses notes, dated 06/05/12 revealed that at 4:00 a.m. the resident had an unwitnessed fall at the bedside. Per the hospital transfer form, dated 06/05/12 no time specified, she fell and hit her head. She was a full code status. She was found lying on the floor between both beds, on her right side with her right arm under her. The right side of her face was lying against the floor with a large amount of blood under her head. She had a hematoma above the right eye. She responded verbally. The BP was 116/58, pulse 76 and respirations 20. The accucheck was 46. The physician and EMS were called. The nurses notes dated 06/05/12 at 4:55 a.m. stated that the resident was alert, awake, and talking to the paramedics. She complained that her head hurt, but the bleeding had stopped. A hematoma was noted above the right eye brow. She was transported to the hospital. On 07/26/12 the facility risk manager (RM) was interviewed several times throughout the day. She stated she was notified of the fall about 5:22 a.m. on 06/05/12. The facility investigated the fall and found it to be adverse. The RM stated at 11:38 a.m. that there were other times when she got up unassisted, but was unable to find documentation of it. The RM stated that the wheelchair lock on the right was " difficult to lock " but they think "she could have locked it". The RM took it out of the room and gave it to maintenance to fix. They, the maintenance department, later informed her that the brake would have to be fixed and" threw it out". The facility did not keep the wheelchair. The RM stated that she then began an investigation and took written statements from the staff. One aide on evening shift wrote that she was informed by the daughter, no date specified, that the wheelchair was not locking properly. She tried to lock it and it was " hard ". The resident used the chair several times after that. On 06/05/12 the nurse wrote she went home at 11:00 p.m. The call light was pinned to her but she " just get out of bed and go to the bathroom " . A statement from the night shift aide , undated, stated he went into the room at 11:15 p.m. to obtain vital signs. The nurse asked him to feed her a snack around 12:00 and she was alert and oriented, " as usual " . At 1:00 a.m. she called to go to the bathroom and he assisted her there and back. He wrote that he went back in at 3:00 a.m. to change her. At 4:30 a.m. he was called to the room by the roommate. Resident #51 had fallen. The rail was down and the call light was on the bed. There was no mention of the position of the wheelchair at the time of the fall. The RM stated neither the aide or the nurse could recall. The aide was unable to be contacted at this time. The RM stated that the facility did a sweep of the wheelchairs after this fall and found that 6 of 96 wheelchairs needed brake repairs. The evaluation document was dated 06/06/12. An invoice dated 06/06/12 stated five packages of wheel lock extensions were ordered. The repairs were completed 06 /11 to 06/15/12. On 07/27/12 the RM provided the surveyor a list of employees that received education regarding reporting equipment that was not working. The RM stated at 11:38 a.m. on 7 /26/12 that after the fall, the resident 's daughter came in to get her belongings. She stated that the daughter informed her on 06/05/12 that the resident had been sent by helicopter to a level three trauma hospital about two hours after arriving at the local hospital from the facility. The RM then called the hospital case manager and was told that she was stable and neurology had signed off. The RM confirmed that the resident had a subdural hematoma about 1.5 cm in size , diagnosed by CAT scan at the local hospital prior to the helicopter transfer. The RM stated she called the trauma hospital on 06/05/12 at 3:15 p.m. and spoke with the ICU nurse. The resident was stable. They were not permitted to give other information to her. 2. Observation on station 2 at 3: 50 p.m. revealed a room behind the open nursing station that contained resident records. The room door was propped open with a door stop . In this room a closet was observed with both closet doors wide open. Observation in this closet revealed tube feeding supplies and solutions, mouth wash, normal saline, shampoo, razors, deodorant, denture cleaner, A& D ointment, germicidal wipes. These items were accessible to anyone who entered the room . No staff were observed to be in the nursing station or in the are of this room from 3: 50 p.m. to 4 : 00 p.m. There was a nurse in the hall but she was not in visual site of this room . Residents were observed to be in the hall and in the day room across from the nursing station